i^ 1 



PRACTICAL GUIDE 



FOR MAKING 



POST-MORTEM EXAMINATIONS, 



AND FOR THE STUDY OF 



MORBID ANATOMY, 



WITH 



DIRECTIONS FOR EMBALMING THE DEAD. AND FOR 

THE PRESERVATION OF SPECIMENS OF 

MORBID ANATOMY. 



BY 

A A R. THOMAS, M. D. 

Professor of Anatomy in the Hahnemann Medical College of Philadelphia; Lecturer on Artisti 

Anatomy in the Pennsylvania Academy of Fine Arts, and Philadelphia School of . 

Design ; Member of the American Institute of Homoeopathy ; 

General Editor of American Journal of Homoeopathic 

Materia Medica, Etc., Etc. 




FOR SALE BY 

BOERICKE & TAFEL,^/ 



NEW YORK: 
No. 145 Grand Street. 



PHILADELPHIA : 
No. 635 Arch Street. 

73. 




3 1'< 



Entered according to Act of Congress, in the year 1873. by 

A. R. THOMAS, M. D.. 
In the Office of the Librarian of Congress at Washington. 



JAMES E. KRVDEK. 

PRINTER, 

SOUTH SEYEN'IH STREE'J 

PHILADELPHIA. 



PREFACE. 



The following work has been prepared with a view of 
supplying a want, the existence of which has long been 
felt by the author, both in his private practice and public 
teaching. JSTo pretension is made of offering a complete 
work on Morbid Anatomy, the object having been, 
merely to present the practitioner and student with a prac- 
tical guide for making post-mortem examinations, to give 
them hints as to what they are to look for in such cases, 
and, finally, to aid them in recognizing the various morbid 
appearances as they are exposed to view. 

The work is divided into four parts. Parts I, II and III, 
corresponding to the three great divisions of the body — 
the Head, Chest and Abdomen. Part IV, is devoted to 
miscellaneous subjects, and contains chapters on the Bones; 
Joints ; Tumors ; Effects of Poisons ; Medico-Legal Autop- 
sies ; On Embalming the Dead ; and On the Preservation 
of Morbid Specimen. 

A few illustrative cases have been introduced, and 
occasional reference made to morbid specimens in the 
Museum of the Hahnemann College. 

The following works have been consulted in the pre- 
paration of the book, and as few references have been 
made, this general credit is felt to be due the several 
sources of information : Rokitansky's, Craigie's, Jones 



PREFACE. 

and Sievecking's, and Green's Pathological Anatomy ; 
Rindfieish's Pathological Histology ; Paget's Surgical His- 
tology ; Raue's Pathology ; Murchison, on the Liver ; 
Hope, on the Heart; Brinton, on the Stomach; Stewart, 
on the Kidney ; Gross' Surgery ; Christison on Poisons ; 
Casper and Taylor's Medical Jurisprudence. 

Acknowledgment should here be made of the valuable 
assistance rendered by Drs. W. H. Bigler and John N. 
Mitchell, in carrying the work through the press ; and of 
the kindness of Mr. J. H. Gemrig, in the loan of the 
electrotype plates which embellish the preliminary chapter. 

Conscious that the work is not without defects, it is 

still presented to the profession, with the hope that it 

may be found to answer the purpose for which it was 

designed. 

A. R. THOMAS, 

937 Spruce Street. 
March, 1873, 



CONTENTS. 



XV 



Introduction, . . . . . . 17 

Preliminary Chapter. 

Instruments and General Directions. . . 21 



PART I. 

THE HEAD AND SPINE. 

CHAPTER I. 
The Operation. 

On the Head and Spine, ... 27 

CHAPTER II. 

Pathological Conditions. 

Section I. — Of the Skull, .... 34 

Fracture ; Caries ; Thinning ; Increased Thickness, 35 

Section II. — The Membranes of the Brain. 

1. The Dura Mater, ..... 36 

Inflammation; Thickening; Fibrinous Clots, . 37 

Tubercular Deposits ; Tumors, . . 3-8 

2. Arachnoid and JPia Mater. 

Pacchionian Bodies ; Inflammation ; Serous Effusions ; 
Sanguineous Effusions, ... 38 

Section III. — Of the Brain. 

What to notice ; Inflammation ; Softening ; Abscess ; 
Hardening ; Hypertrophy ; Atrophy ; Tumors of 

(vii) 



Vlll CONTENTS. 

the Brain ; Adenoid Tumors ; Scrofulous Tumors ; 
Adipose Tumors; Cholesteroma ; Cartilaginous 
Tumors; Calcareous Deposits; Encysted Tumors; 
Blood Cysts; Cancer; Melanosis; Syphilitic Tumors ; 
Obstruction of Arteries; Degeneration and Calci- 
fication of Arteries, .... 47 

Section IV. — Of the Spinal Cord. 

1. The Membranes. 

Inflammation ; Tubercular Deposits ; Serous Effusion, 60 

2. Spinal Marrow. 

Inflammation ; Softening ; Hardening ; Atrophy ; 
Morbid Growths, .... 62 



PART II. 

THE NECK AND CHEST. 

CHAPTER I. 

Operation on the Neck and Ohest. 

CHAPTER II. 

Pathological Conditions of the Organs. 
Section I. — Of the Tongue. 

Cancer ; Syphilitic Ulcer ; Tumors ; Ranula ; Hyper- 
trophy, ..... 68 

Section II. — Of the Larynx and Trachea. 

Inflammation ; Ulceration ; (Edema ; Necrosis of 
Cartilages ; Abscess ; Tumors ; False Membranes, 69 

Section III. — Of the Pharynx and (Esophagus. 

Inflammation; Ulceration; Stricture; Dilatation; 
Tumors, ..... 72 

Section IV. — Of the Pericardium. 

Inflammation ; Adhesions ; Effusions ; Morbid Growths, 73 



CONTENTS. IX 

Section V. — Of the Heart. 

1. Inflammatory Affection. 

Pericarditis ; Endocarditis, ... 76 

2. Valvular Affection. 

Thickening ; Calcification ; Atrophy, . . 77 

3. Changes Affecting Size. 

Hypertrophy ; Dilatation ; Atrophy, . . 79 

4. Morbid Condition of the Walls. 

Fatty Degeneration, .... 82 

5. Morbid Growths. 

Tumors; Cancer; Melanosis; Hydatids; Ossification 
of Coronary Arteries; Abscess; Malformations; 
Aneurism ; Rupture, .... 84 

6. Displacements. 

Ectopia Cordis ; Transposition, . . . 87 

7. Contents of Cavities. 

Heart Clots, 88 

Section VI. — The Aorta and Arteries Generally. 

Inflammation ; Fatty Degeneration ; Ossification ; 
Aneurism; Rupture, .... 98 

Section VII. — Of the Pleura. 

Inflammation ; Plastic Effusion ; Adhesions ; Serous 
Effusion ; Sero-Purulent Effusions ; Pneumothorax, 103 

Section VIII. — Of the Lungs and Bronchial Tubes. 

Pneumonia ; Congestion ; Red Hepatization ; Gray 
Hepatization; Suppuration and Abscess; Metas- 
tatic Abscess; Gangrene ; Pulmonary Haemorrhage ; 
Pulmonary Apoplexy ; Emphysema, . . 106 

Tubercular Disease of the Lungs, . . . 117 

Post-mortem Appearances in, . . . .118 

Morbid Growths. 

Cancer; Melanosis; Hydatids, . . .. 120 

The Bronchial Tubes. 

Bronchitis; Narrowing of ; Dilatation of, . 123 

The Mediastinum. 

Inflammation ; Abscess ; Tumors, . . 126 



X CONTENTS. 

PART III. 

THE ABDOMEN AND PELVIS. 

CHAPTER I. 

The Operation, . . . . .127 

CHAPTER II. 

Pathological Conditions of the Peeitoneum and 
Alimentary Tract. 
Section I. — Of the Peritoneum. . 

Congestion ; Inflammation ; Fibrinous Exudations ; 
Suppuration; Gangrene; Ascites; Morbid Growths, 133 

Section II. — Of the Stomach. 

Post-mortem Changes ; Gastritis; Effects of Poisons ; 
Gastric Ulcer ; Hemorrhagic Erosion ; Softening ; 
Cirrhosis; Atrophy; Dilatation; Morbid Growths, 137 

Section III. — The Intestines. 

Malformations; Inflammation; Ulceration; Dilatation; 
Contraction; Displacements; Incarceration; Vol- 
vulus ; Intussusception ; Eupture ; Ulcer and Fissure 
of the Anus ; Fistule ; Haemorrhoids ; Morbid 
Growths; Parasites, .... 149 

Section IV. — The Pancreas. 

Anomalies; Hypertrophy and Atrophy; Inflamma- 
tion; Fatty Degeneration; Dilatation of Ducts; 
Cancer, ..... 160 

Section V. — The Spleen. 

Congenital Anomalies ; Hypertrophy and Atrophy ; 
Displacements^ Eupture; Inflammation; Thick- 
ening of Capsule ; Degeneration ; Morbid Growths, 162 

Section VI. — Of the Liver. 

Normal state of ; Congestion ; Hemorrhagic Effusion ; 
Perihepatitis; Scar-like Marks; Hepatitis; Secon- 
dary, Pyemic or Metastatic Abscess; Degenerations 



CONTENTS. XI 

of the Liver; Waxy, Lardaceous or Amyloid Liver; 
Atrophy ; Simple Atrophy ; Acute or Yellow 
Atrophy ; Chronic Atrophy ; Cirrhosis, or Hob- 
nail Liver; Hypertrophy; Morbid Growths; 
Parasites, . . . . . 165 

Affections of the Gail-Bladder and Ducts. 

Inflammation ; Dilatation ; Morbid Growths ; Biliary 
Calculi, 189 

CHAPTER II. 

The Urinary Apparatus. 
Section I. — The Kidneys. 

Congenital Anomalies ; Congestion ; Haemorrhage ; 
Nephritis ; Pyelitis ; Abscesses ; Inflammation of 
Capsule; Morbus Brightii; Fatty Degeneration; 
Dislocated Kidney ; Morbid Growths ; Parasites, 193 
" The Ureters. 

Dilatation ; Inflammation ; Morbid Growths, . 205 

The Suprarenal Capsules. 

Inflammation and Degeneration ; Haemorrhage ; Mor- 
bid Growths, . .. . , . 207 

Section II. — The Urinary Bladder. 

Malformations; Dilatation; Hypertrophy; Contrac- 
tion; Inflammation; Morbid Growths; Parasites, 208 
Of the Urethra. 

Malformations; Inflammation; Dilatation and Con- 
traction; Stricture; Rupture; Morbid Growths; 
Urinary Calculi, ..... 208 

CHAPTER III. 

The Male Generative Organs. 
Section I. — The Penis. 

Congenital Anomalies; Hypertrophy and Atrophy; 
Fracture; Paraphymosis ; Balanitis; Herpes; Chan- 
cres ; Morbid Growths, . . . 215 

Section II. — Of the Scrotum. 

Hypertrophy ; Inflammatory (Edema ; Morbid 
Growths, : .... 218 



Xil CONTENTS. 

Section III. — Of the Testicles. 

Congenital Anomalies; Hypertrophy and Atrophy; 
Inflammation ; Hydrocele ; Hsemotocele ; Varico- 
cele ; Morbid Growths, ... 219 

Section IV. — The Seminal Vesicles and Prostate. 

Congenital Anomalies ; Inflammation ; Tubercular 
Deposits, ..... 226 

The Prostate Gland. 

Anomalies ; Hypertrophy and Atrophy ; Inflamma- 
tion ; Abscess ; Morbid Growths, . . 226 

CHAPTER IV. 

The Female Genekative Oegans. 
Section I. — The Pudenda and Vagina. 

1. The Pudenda. 

Congenital Anomalies ; Hypertrophy ; Inflammation ; 
Morbid Growths, .... 230 

2. The Vagina. 

Anomalies; Occlusion; Dilatation; Laceration and 
Rupture ; Inflammation ; Morbid Growths, . 230 

Section II. — The Uterus. 

Anomalies ; Hypertrophy and Atrophy ; Hydro- 
metra ; Malpositions ; Haemorrhages ; Peri- or 
Retro-Uterine Hsemotocele ; Inflammation ; Ulcer- 
ation ; Morbid Growths, ,. . . 235 
Morbid Conditions following Parturition. 

Rupture; Puerperal Inflammation, . . 241 

Extra- Uterine Pregnancy, .... 244 

Section III. — The Ovaries and Fallopian Tubes. 

1. The Ovaries. 

Malformations ; Inflammation ; Abscess ; Morbid 
Growths, ..... 247 

2. The Fallopian Tubes. 

Anomalies ; Inflammation ; Morbid Growths, . 251 

Section IV. — The Mammae. 

Anomalies ; Hypertrophy ; Atrophy ; Inflammation 
and Abscess ; Morbid Growths, . . 252 

The Male Mammae, ..... 257 



CONTENTS. X1U 

PART IV. 

MISCELLANEOUS SUBJECTS, 

CHAPTER I. 

Of the Peeiosteum and Bones. 
Section I. — Of the Peeiosteum. 

Inflammation ; Ulceration ; Malignant Disease, 258 

Section II. — Of the Bones. 

Inflammation and Abscess; Caries; Necrosis: Ra- 
chitis; Mollities Ossium; Morbid Growths., . 259 
The Medulla, . . . , 267 

. CHAPTER II 
Diseases of the Joints. 

Malformations ; Morbid Condition of Synovial Mem- 
branes; Morbid Condition of Bursas ; Morbid 
Condition of Cartilage ; Ulceration of Cartilage ; 
Chronic Rheumatic Arthritis ; Serofulous Arthritis, 268 
Diseases of the Spinal Column, .. „ . 272 

CHAPTER III, 
Of Tumoes. 

1. Benign or Non-Malignant Tumors, „ . 274 

2. Malignant Tumors, . 286 

CHAPTER IV. 

POST-MOETEM APPEAEANCES IN DEATH FEOM Un- 

natueal Causes. 

1. Death from Poisoning, .... 294 

2. Death from Suffocation, . . . 300 

3. Death from Hanging or Strangling, . . 301 

4. Death from Drowning, .... 302 



XIV CONTENTS. 

CHAPTER V. 
Medico-Legal Questions. 

1. Method of Conducting a Medico- Legal Autopsy, . 304 

2. Questions Relating to New-Horn Children, . 307 

3. Supposed Period of Death, . . . 312 

4. The Drobable Cause of Death, . . . 317 

CHAPTER VI. • 
On Embalming the Dead, .... 320 

CHAPTER VII. 

Preservation of Specimens; of Morbid Anatomy, 326 



INTRODUCTION 



Before entering upon the study of any subject, it is of 
moment that the student be thoroughly convinced of the 
importance of the knowledge which he is about seeking to 
acquire, since his zeal in its pursuit will, in most cases, be in 
proportion to this conviction. We will, therefore, before 
entering upon the subject proper of this book, present in few 
words, some considerations on the importance of a study of 
morbid anatomy as revealed by post-mortem examinations. 

The necessity of a study of anatomy and physiology by a 
medical student, is now so universally recognized, that an 
attempt to prove its importance would seem deserving only 
of ridicule ; but the ignorance of many practitioners on the 
subject of morbid anatomy, shows that this study has yet 
to vindicate its claim as a necessary branch of a medical 
education. 

From a purely theoretical standpoint, the educated physi- 
cian — one whose motto is Esse, non videri — after combating 
a disease in vain, should not feel content to remain in 
ignorance of its real nature, so far as discoverable by an- 
atomical changes, capable of being recognized after death, even 
had he no prospect of adding thereby one jot to his practical 
acquaintance with disease or to his power to combat it ; yet 
his scientific conscience (if we may be allowed the expression) 
ought not to rest satisfied until, in all doubtful cases, his 
ante-mortem diagnosis be confirmed or overthrown, and his 
conception of the case completed in all its details by a post- 
mortem examination. 

2 (17) 



18 INTRODUCTION. 

Besides this purely individual scientific interest, there are 
weightier practical reasons for an acquaintance with this 
branch of medical science by the physician as practitioner. 

Among the almost innumerable questions upon medical, 
theological, and miscellaneous subjects which the American 
public feels at liberty to propound to its medical advisers, 
none are of more frequent occurrence and none are more 
justifiable than the two: "What is the matter with the 
patient?" and "Will he, or can he, recover?" and to none 
is an answer more imperatively demanded. The public very 
naturally, and with reason, requires on the part of a physi- 
cian the ability to make a diagnosis and a prognosis. It 
will not be satisfied with being told that the name of the dis- 
ease is of no importance, that the doctor only wants to hear 
the symptoms ; that he does not cure diseases, but removes 
the symptoms of disease, dec. Only an exceedingly well- 
trained public will accept these truisms as an equivalent for 
diagnostic skill. Hence, it is the physician's interest, as 
well as his duty, as we shall see, to seek, in all cases, to 
make a diagnosis, no matter how difficult the task may 
prove to be. The question how far his treatment will be 
modified by his diagnosis is a question of therapeutics, and 
does not belong here ; but certain it is, that a mere com- 
batal of the symptoms as isolated phenomena cannot be 
regarded as fulfilling the whole duty of a conscientious 
physician. 

The ability to make a diagnosis, and consequently prog- 
nosis, depends upon a knowledge of pathology, with a 
knowledge of symptoms as signs of pathological states and 
changes ; and as such they must be critically examined and 
their true import discovered, if possible. Thus treated, we 
arrive, by various processes of reasoning, at a diagnosis, 
under which the symptoms fall into their natural order of 
importance, and we run but little risk of contending with 
remote subjective symptoms (of great importance in differen- 



INTRODUCTION. 19 

tial therapeutics) to the neglect of more important, though 
perhaps less prominent ones. 

Besides this, we are, in a measure, prepared to foretell the 
probable course of a disease, and can, therefore, in many 
cases, adopt anticipatory measures, while in all we will be 
guarded against the error, so often committed, of ascribing 
to the remedy used the so-called " aggravations" which are 
often only natural symptoms of the unchecked and, perhaps, 
entirely uninfluenced morbid process. Such knowledge 
serves thus, by purifying our experience, to guard us against 
self-deception, and to prevent us from misleading others by 
reports of cures of diseases existing only by virtue of a false 
diagnosis. 

A knowledge of pathology, furthermore, places in our 
hands a thread which can guide us through the labyrinth of 
our vast materia medica, and which enables us, from the 
myriad of symptoms, to eliminate the non-important ones. 
It shows us the "bearings" of the medicines and their 
various specific ranges, thus materially facilitating the choice 
of a remedy. 

Again, medical science is virtually based upon pathology, 
and we see, therefore, how important, nay, how absolutely 
necessary, to the progress of the former is the study of the 
latter. The practice of medicine as an art can never be 
advanced knowingly by those who neglect its cultivation as 
a science. While each one may practice the art according 
to his own convictions, true medical science stands above alii 
the belittling, bigoted prejudices of the schools. Here,, 
every one claiming the name of an educated physician catt 
and ought to work. 

The wild vagaries of former ages, when philosophy set u}> 
purely theoretical views, under which observed phenomena- 
were compelled to arrange themselves, have warned the- 
present age to be guided solely by sober and exact observa- 
tions and investigations; and it needs no proof that, in the 



20 INTRODUCTION. 

advancement of our knowledge of disease, these are best 
accomplished by frequent post-mortem examinations, which 
thus become a necessary adjunct to a proper study of 
pathology. 

In all cases of interest, therefore, the physician should 
feel it a duty which he owes to himself and the profession 
at large, to seek permission to make a post-mortem exami- 
nation ; but in order that the fullest benefit may be derived 
from the same, he must know how to look for what he is in 
search of, and how to recognize* it when found. 

To furnish this knowledge is the object of the following 
pages, to which we herewith introduce the reader. 



PRELIMINARY CHAPTER. 



INSTRUMENTS AND GENERAL DIRECTIONS. 

The Post-mortem Case, as prepared by the instrument 
makers, will be found to contain, usually, the following 
instruments: 




1. A set of ordinary dissecting scalpels, four or five in 
number, and of graduated sizes, including one heavy carti- 
lage knife. 



2. A brain knife with a long blade, for slicing the brain. 




3. Chisels, of one or both the accompanying forms, for use 
in opening the head or spine. 




4. An iron mallet or hammer, with a hook on the end of 
the handle for tearing off the culvarium. 

(21) 



22 



INSTRUMENTS AND GENERAL DIRECTIONS. 




5. An enterotome, or scissors with blunt, hooked point, 
for splitting open the intestinal canal. 




6. A saw with movable back ; this arrangement permit- 
ting of a deeper cut, in dividing large bones. 




7. The rachitome, a chisel-like instrument, to be used 
with the hammer in opening the spinal canal. 




8. The double saw, used for dividing the laminae of the 
vertebrae. A side view of the instrument being given in the 
cut, one blade only is seen. The two are attached to one 
handle, placed parallel with one another, and about one and 
one-fourth inches apart. After the soft tissues have been 



INSTRUMENTS AND GENERAL DIRECTIONS. 23 

removed, this saw is used by passing the spinous processes 
between the two blades, and thus dividing both laminae at 
once. 




9. A skull clamp, for steadying the head while removing 
the calvarium. After the removal of the scalp, this instru- 
ment may be employed, and be of much service for the 
above object. It is applied by placing the open end of the 
instrument over the crown of the head, turning down the 
screws, and thus fastening it just above the line of division 
of the bone. The arched end of the instrument now serves 
as a handle for turning or steadying the head. 

10. Rib-shears, for dividing the ribs where that operation 
is found desirable. 

11. A tube for inflating the lungs, and an ordinary blow- 
pipe. 

12. Dissecting forceps, tenacula in handle and with chain, 
grooved director, and assorted needles, straight and curved. 

While a post-mortem case with all of the above instru- 
ments is very convenient, and important even, where there 
is frequent occasion for its use, still its absence should never 
deter the physician from making an examination where the 
ordinary dissecting case may be had ; and with the country 
physician generally, this case is all that is absolutely essen- 
tial, as a common carpenter's saw and chisel may at any 
time be found, in cases where the head is to be opened ; 
while for opening the chest and abdomen, the dissecting case 
contains everything that is essential. 



24 PRELIMINARY PREPARATIONS. 

Instruments used in post-mortem examinations should 
never be employed for operating upon the living, without 
first being, repolished by the instrument maker, and the 
handles disinfected by careful cleaning in a solution of 
permanganate of potash. 

PRELIMINARY PREPARATIONS. 

The Preliminary Preparations at the place of the 
operation should consist in providing a sponge for absorbing 
fluids ; newspapers and old cloths for filling cavities or 
wrapping up any morbid specimen that it may be desirable 
to preserve : a couple of quarts of clean sawdust or wheaten 
bran for throwing into the cavities before closing them up, 
and thus absorbing any excess of fluids ; stout thread or 
twine for tying intestines and closing the cavities ; lard or 
sweet oil for oiling the hands ; a couple of empty slop- 
buckets for receiving the fluids, bloody water, <fec, and 
plenty of water, hot and cold, with towels and soap. If 
the floor of the room is carpeted, to protect it from accident, 
a piece of old carpet, or quilt, or oilcloth should be spread 
alongside the table or box where the examination is made. 
Oare should be observed to have all these matters provided 
before the operation is commenced, when the door should 
be fastened, that there may be no intrusion, by accident or 
otherwise. 

In preparing the body for examination, if the head is to 
be opened and the body is in an ice-box, it will be absolutely 
necessary that it be removed. Placing the cover of the box 
on the floor, the body may be lifted out and placed on the 
same, when both may be again placed on the top of the box 
or on a table, for the examination. If only the chest and 
abdomen are to be examined, it will hardly be necessary to 
lift the body from the box. In all cases, the sheet in which 
the body is placed, with the underclothing, (the latter having 



TIME FOR MAKING THE EXAMINATION. 25 

been split down the centre,) should be carefully turned aside, 
and care observed during the operation to avoid as much as 
possible soiling them with blood-stains. 

Precautionary Measures. That there is a certain 
amount of danger from absorption of virus in case of cuts or 
scratches received while conducting a post-mortem examina- 
tion, cannot be denied ; yet this danger is by no means 
common to every case. In the great majority of instances, 
probably no mischief whatever would follow such an acci- 
dent, the danger being confined almost wholly to cases of 
peritoneal inflammation, erysipelas, and certain malignant 
forms of disease. In all cases, however, it will be well to 
look for any scratch, cut, or abraded point on the hands or 
fingers, and first touching them with nitrate of silver, cover 
them finally with collodian. Smearing the hands well with 
lard or olive oil will also aid much in preventing absorption. 

Should an accidental cut be received during the operation, 
it will be prudent, in all cases, to wash the hands at once, 
squeeze and suck the part, to favor bleeding, and, finally, 
touch with a crystal of nitrate of silver. Punctures with a 
needle or slight scratches which do not bleed are, probably, 
more dangerous than a free cut ; hence, in cases of suspected 
danger, when a puncture has been received, it would be 
safer to make a free incision with a knife, thus inducing; 
bleeding, which will favor the washing out of any virus, and 
finally, use the caustic. 

Time for Making the Examination. As a rule, 
post-mortem examinations should be made as soon after 
death as a due regard to the feelings of friends will permit, 
say within twelve to twenty-four hours ; a longer delay 
would give time for such decomposition as not only to make 
the examination extremely disagreeable, but, from change of 
structure in tissues and organs, much less satisfactory. In 
cold weather, however, or where the body has been placed 



26 PRELIMINARY PREPARATIONS. 

in ice soon after death, as is the custom in most cities, the 
examination may be postponed to any convenient time 
before the burial. 

Notes. In all important cases, notes should be taken 
down by an assistant, on the spot, as dictated by the opera- 
tor ; heading these by the name and age of the patient and 
a brief sketch of the disease. In medico-legal cases, this is 
to be conducted with particular care, as will be pointed out 
hereafter. 

Consent of Friends. Much difficulty will sometimes 
be met in obtaining the consent of friends for a post-mortem 
examination, the idea of the mutilation of the body of the 
deceased striking many with particular dread. With a little 
tact and management, however, consent may, in the majority 
of instances, be obtained. Instead of speaking to a single 
member of the family and leaving him or her to bring the 
subject before others, in all doubtful cases it will be better 
for the physician to see all the interested parties himself, 
either together or separately, and endeavor to interest them 
in the case, by pointing out the peculiar character of the 
disease, the satisfaction which the friends will themselves 
derive from a verification of the diagnosis of their physician, 
while, when too late, they may regret having withheld their 
consent; also the scientific interest which attaches to the case, 
and the benefit which will no doubt accrue to medical science 
through a post-mortem examination, and the possibility that 
the lives of others may depend upon a knowledge of the true 
state of this case. These, with like considerations, adapted 
with ready tact to the class of persons to be persuaded, will, 
in the majority of instances, be enough to overcome all 
scruples, especially when joined to the assurance that the 
examination will be so conducted as to leave no visible trace 
of the operation with which to embitter the remembrance 
of the well-known countenance. 



PART I. 

THE HEAD AND SPINE. 



CHAPTER I. 
THE OPERATION. 

In opening the head for a post-mortem examination, let 
a thick block be placed beneath the occiput, when, after 
having carefully parted and turned aside the hair, an incision 
may be made through the scalp, over the top of the head, 
from ear to ear. The back of the scalpel being placed next 
the head, the point may be pushed in advance, thus dividing 
the tissues without danger of injuring the edge of the instru- 
ment by bringing it in contact with the bone. 

From the loose connection of the tendon of the occipito- 
frontalis muscle to the periosteum, by the use of the handle 
of the scalpel, the flaps of the scalp may readily be turned 
aside, the anterior over the face, the posterior on the back 
of the neck. The skull clamp may now be applied, which 
will be of great service in steadying the head while using the 
saw. Instead of dividing the skull in a circular manner, as 
is usually done in the dissecting-room, it will be better to 
start the saw above the frontal eminences and run obliquely 
down towards the mastoid process, meeting this line by 
another commencing at the occipital protuberance and carried 
horizontally forwards, thus giving a wedged form to the por- 
tion removed. The advantage of this method consists in our 

(27) 



28 OPERATION ON HEAD AND SPINE. 

being better able to hold the parts in position as they are 
replaced, as in the old method, from the readiness with which 
the parts move upon one another, the calvarium is liable to 
slide forwards or backwards from its position, thus producing 
an unsightly ridge across the forehead, which will more 
or less plainly show through the integument. With young 
children, a strong pair of scissors may be used instead of 
the saw in dividing the calvarium. 

In using the saw, care should be observed not to injure 
the dura-mater ; hence it will be better not to attempt to 
divide both tables with that instrument, but rather depend 
upon the chisel or rachitome for breaking away the inner 
table. To avoid the sound which would attend the use of 
the iron hammer, which, if heard by members of the family, 
might excite unpleasant feelings, a billet of wood or wooden 
mallet may be used; or, these not being at hand, the head of 
the iron hammer may be muffled with a towel, so as mate- 
rially to deaden the sounds. The inner table having been 
divided, the calvarium may be pried off with the chisel, or 
torn away with the hook on the handle of the hammer. 
This, from the close adhesion of the dura-mater to the bones, 
will generally require considerable force. 

The calvarium having been removed, and the superior 
longitudinal sinus opened, and the condition of its contents 
noted, the dura-mater, after its careful* examination, may 
be cut through with the knife or scissors in the line of the 
division of the bone. The membrane may now be lifted up, 
when adhesions will be found between its under surface and 
the pia-mater, along either side of the falx cerebri. These 
should not be mistaken for results of inflammation, as they 
sometimes are, they being simply the points of entrance of 
the veins of the pia-mater into the superior longitudinal 
sinus. These having been divided, with the falx near its 
attachment to the crista galli, the whole may be turned 
back, exposing the brain. 



REMOVAL OF BRAIN. 29 

To remove the latter, take away the block from beneath 
the head, and lifting the anterior lobes of the brain, divide 
successively the several pairs of nerves as they appear in 
sight, with also the tentorium on either side, and as the brain 
falls back into the left hand, the knife may be passed down 
into the foramen magnum, and the medulla oblongata and 
vertebral arteries divided, when the whole may be lifted 
from its position. More or less blood with the cerebro- 
spinal fluid will necessarily flow off during this operation, 
to secure which, a bucket should be placed beneath the edge 
of the table, over which the head should slightly project. 
In dropsy of the brain, although the fluid is mainly in the 
ventricles, it may escape during the operation and be caught 
in the same manner. 

The external surface of the brain having been carefully 
examined, the hemispheres may be sliced off to a level with 
the corpus callosum, when, by removing the latter, the 
cavities of the lateral ventricles will be exposed. After a 
careful inspection of the several objects seen here, the fornix 
and velum interpositum may be removed, opening thus into 
the third ventricle. Slices may now be taken off the corpora 
striata and optic thalami, with deeper portions of the hemi- 
spheres, and sections made of the crura cerebri cerebellum 
and medulla oblongata, thus giving an opportunity of judging 
of the condition of all those parts. 

After the removal and examination of the brain, attention 
should be given to the base of the skull. The lateral and 
other sinuses should be laid open, the dura mater, as far 
as possible, torn away, and the bones examined for fractures, 
caries, abnormal growths, etc. 

" The simplest method for removing the ear for the sake of 
dissection is, after the removal of the calvarium in the usual 
way, to take out both the petrous bones together by means 
of two transverse vertical sections, one in front of the two 



30 OPERATION ON HEAD AND SPINE. 

petrous bones and the other posterior to them. The anterior 
of these sections should pass in a line a little anterior to the 
anterior clinoid processes, and the posterior in a line through 
the posterior third of each mastoid process. By means of 
these two sections, the trumpet-shaped extremity of each 
Eustachian tube, a portion of the mucous membrane of the 
fauces, and the whole of each petrous bone, together with the 
mastoid processes, can be taken out. 

" The disadvantage of this procedure is the disfigurement 
which is apt to ensue from the falling in of the face. To 
avoid this disadvantage, another mode of removing the ear 
may be resorted to. This consists in taking out each petrous 
bone separately in the following manner : The calvarium hav- 
ing been sawn off, an anterior section is to be made in each 
side in the same line as in the above plan, but extending 
only as far as the outer part of the body of the sphenoid 
bone ; a posterior section in each side is then to be made, as 
in the first plan, but not extending farther inwards than the 
basilar process of the occipital bone. These two sections are 
to be made with a saw or with a chisel and hammer. The 
apex of each petrous bone is then to be separated from the 
sphenoid and occipital bones, and each petrous bone (the 
outer ear and integument being detached and reflected down- 
wards) is to be drawn outwards, taking care, by inserting 
the scalpel deeply, to remove as much of the soft parts as 
possible. 

"The organ of hearing having been removed, the dissection 
may be conducted in the following manner : The auditory 
nerve in its meatus should be first carefully examined, pre- 
suming that a previous inspection has been made of the 
portion of the brain to which the portio mollis and portio 
dura nerves are attached. The size of the external meatus 
having been ascertained by allowing a strong light to fall 
into it, its anterior wall is to be removed by the cutting 
forceps. 



DISSECTION OF THE EAR. 31 

"The state of the epidermis, the ceruminous glands and 
secretion, the dermis, periosteum and bone is to be noticed. 
The outer surface of the membrani tympani is then to be 
examined ; also the state of its epidermoid and dermoid 
laminae, its degree of tension, and the amount of motion 
possessed by the malleus when pressed upon by a fine point. 
The next step is to ascertain the condition of the guttural 
portion of the Eustachian tube, to lay open the cartilaginous 
tube with the scissors, and then to expose the cavity of the 
osseous portion by means of the cutting forceps. In doing 
this, the tensor tympani muscle is exposed ; its structure 
should be examined, and if it has not a healthy appearance, 
portions of it should be submitted to microscopic inspection. 
The upper wall of the tympanum is next to be cut away by 
means of the cutting forceps. In doing this, great care must 
be taken not to disturb or disconnect the malleus and incus, 
which lie immediately beneath it. After the tympanic cavity 
has been exposed, the first step is to pull the tensor tympani 
muscle and ascertain how far it causes a movement of the 
membrana tympani and ossicles. The incus and stapes are 
now to be touched with a fine point, so as to ascertain their 
degree of mobility ; the tendon of the stapedius muscle is 
also to be pressed upon. The condition of the mucous mem- 
brane of the tympanum and of the mastoid cells is then to 
be ascertained, and any peculiarity of the cavity, the exist- 
ence of bands of adhesion, etc., to be noted. 

"The most delicate parts of the dissection, viz., that of the 
internal ear, must now be undertaken. The cavities of the 
vestibule and cochlea are to be exposed by removing a small 
portion of the upper wall of each. Before reaching the ves- 
tibule, the superior semi-circular canal will be cut through 
and removed ; the membranous canal should be drawn out 
and inspected. As the cavities of the vestibule and cochlea 
are laid bare, it is desirable to see that the quantity of peri- 
lymph is natural, as well as its color and consistence. The 



32 OPERATION ON HEAD AND SPINE. 

outer surface of the membranous labyrinth having been 
observed, it should be opened so as to expose the endolymph 
and otoliths, portions of all which parts should be removed 
for microscopic inspection. This having been effected, the 
remaining membranous semi-circular canals are to be ex- 
posed, and the connection of the base of the stapes to the 
fenestra ovalis carefully examined. The last stage of the 
dissection consists in removing parts of the lamina spiralis, 
in examining them microscopically, and- in exposing from 
within, by following the course of the scala tympani, the 
membrane of the fenestra rotunda. 

"The only part which now remains unexamined is the 
stapedius muscle ; in order to expose it, the course of the 
aquseductus Fallopii, beginning at the sty lo-mastoid foramen, 
should be followed until the base of the pyramidal eminence 
containing the muscle is reached."* 

The Eyes, with the optic nerves, may be most conve- 
niently removed for examination, by breaking up the roof of 
the orbit with the hammer, and, after the removal of the 
fragments of bone, dissecting away the fat and muscles 
until the ball is exposed, when, with the scissors, the tunics 
of the latter may be divided just behind the conjunctival 
attachment, and the ball removed with the optic nerve. 
The front portion of the eye being left in position, by filling 
the cavity behind with a little cotton or paper, any flattening 
may be prevented, and thus any appearance of loss of parts 
avoided. 

The examination having been completed, the brain may 
be replaced, the calvarium put in position, the scalp brought 
over the same and united with stitches, the arranging of the 
hair effacing all traces of the operation. 

* Toynbee on the Ear. 



THE SPINAL CORD. 33 



THE SPINAL CORD. 



For the removal of the spinal cord, place the body in a 
prone position, and make an incision the whole length of the 
back, over the spinous processes of the vertebrae. Then 
raise up and turn aside all the muscles with the integument, 
exposing the laminae of the vertebras. The latter may now 
be divided with the single or double saw, the rachitome or 
chisel being used to complete the operation, when the laminae, 
with the spinous processes, may be removed in one strip, 
exposing the cord enclosed in its membranes. 

The roots of the nerves may now be divided, and the cord, 
enclosed in its sheath, removed ; care being observed not to 
handle the parts roughly while so doing. The dura mater 
may now be split open for the examination of the cord. 
Should it be desired to preserve any portion for microscopic 
examination, it may be suspended in a solution of bichromate 
of potass, xx to xxx grs. to the ounce of water, and in a few 
days transferred to a solution of chromic acid, ij grs. to the 
ounce of water, where it should remain until sufficiently 
hardened to be cut into thin sections. 

The examination completed, the parts may be replaced 
and the incision sewed up. 



34 PATHOLOGICAL CONDITIONS. 

CHAPTER II. 

PATHOLOGICAL CONDITIONS. 
Section I. OF THE SKULL. 

[Notice in examination, condition of scalp; cuts, bruises, extrava- 
sation of blood, &c. Cranium — Color, smoothness or roughness of 
exposed surface ; fractures, their position and relation to injuries of 
scalp. Removal of Calvarium — Adhesion of dura mater : inner sur- 
face of ; smooth or rough ; seat of same ; deposit of new bone ; depres- 
sion of inner table ; thickening or thinning of. State of fontanelles in 
children ; condition of frontal sinuses ; condition of base of skull noted 
after removal of brain ; fractures ; condition of petrous portions of 
temporal bones, &c] 

Fracture,, In a post-mortem examination of the head, 
after death from a blow or fall upon that part, a fracture 
may be disclosed of which there was no external trace. 
Owing to the greater thinness and brittleness of the inner 
table, it is possible for this to be fractured without any cor- 
responding injury to the external ; such fracture may possi- 
bly rupture some of the branches of the meningeal arteries, 
which will be followed by the formation of a clot between 
the bone and dura mater, the pressure of which may be suf- 
ficient to produce death. Owing to the same cause — greater 
brittleness of the inner table — when fracture of the outer 
exists, that of the inner table will be likely to be more 
extensive, accompanied perhaps with depression, of which 
there is no external evidence. 

Again, it will sometimes be discovered that fracture exists 
at a point opposite to that upon which the blow was received, 
on the principle of the " contre coup " of the French ; thus, 
the blow having been received on the occiput, the fracture 
may be found in the frontal region ; or, received on the top 
of the skull, fracture may result at the base. In falls from 
a height, upon the top of the head, the weight of the body, 



OF THE SKULL. S5 

acting through the cervical vertebrae as a propelling force, is 
very likely to produce fracture of the occipital bone. 

Caries may affect any of the bones of the head, but in 
the majority of cases it will be the result of syphilitic or mer- 
curial poisoning. Following an attack of periostitis, the 
inflammation extends to the bone and gradually develops 
the carious ulceration. While the condition is usually con- 
fined to, or at least, most strongly developed upon the outer 
table, it may involve the entire thickness. In syphilitic 
ulceration of the bones of the nasal cavity, the disease may- 
destroy the cribriform plate of the ethmoid bone, and thus-, 
extend to the membranes of the brain.* So also, in 
caries of the petrous and mastoid portions of the temporal- 
bone, which sometimes results from scarlet fever, the disease 
may extend to the inner surface, resulting in the accumula- 
tion of pus within the cranial cavity. 

Along either side of the central portion of the inner surface 
of the calvarium may be usually seen,, at least in the heads, 
of aged persons, a number of irregular, rough pits, varying 
in size and depth, which are not to be mistaken for disease 
of the bone, they being simply impressions of the Pacchionian, 
glands, 

Thinning of the bones of the head will always indicate 
increased pressure from within, induced by hypertrophy 
of the brain, or, as is more frequent, hydrocephalus. Tn the 
latter case, not only thinning, but complete absorption of 
the parietal and other bones may result.f 

Increased Thickness will also sometimes be found.. 
This condition indicates diminished pressure from within,, 
as in atrophy of the brain. The thickening results from a, 

* See No. 509, College Museum. t Id > 473 - 



36 THE MEMBRANES OF THE BRAIN. 

gradual remodeling of the inner table and diploe, so that 
while the exterior of the skull may retain its normal size 
and form, the inner table following the retiring and shrink- 
ing brain, the interval between the two becomes filled with 
the thickened diploe. It has been observed that this hyper- 
trophy is greatest at those parts of the bones where ossifica- 
tion first commences, as at the parietal and frontal eminences. 
It is not confined to old persons, though perhaps more fre- 
quent with them.* 



; Section II. THE MEMBRANES OF THE BRAIN. 
1. The Dura Mater. 

[Notice color and general character of surface ; blood between it 
.•and bone; position of; quantity; coagulated or not. Condition of 
bone — necrosed or fractured; pus between dura-mater and bone. 
Tumors — their position, size, &c. Wounds — their position, extent, &c. 
■Open longitudinal sinus and note contents.] 

This membrane, serving both as a periosteum to the inner 
surface of the cranial bones and as a support to a serous 
membrane — the reflected layer of the arachnoid — is subject 
to affections of a two-fold character, those peculiar to the 
fibrous and serous portions. 

Inflammation of this membrane, may involve either the 
outer fibrous, or the inner serous layer. In the former case, 
the membrane appears congested, red and more or less soft- 
ened. The inflammatory process may result in the forma- 
tion of pus between the bone and dura mater, and even in 
gangrene. The disease may also extend to the adjacent 
portions of the pia mater and brain substance. External 
injuries, fractures of the bones of the skull, inflammation of 
the periosteum, otitis, resulting in caries of the temporal 



See No. 490, College Museum. 



THE DURA MATER. 37 

bone, may all be causes of inflammation of the outer portion 
of the dura mater. 

Inflammation of the inner surface of this membrane, is 
marked by the presence of a net-work of delicate red vessels, 
while the surface is covered by a soft, grayish or yellow 
semi-purulent matter, and may attend cases of pysemic 
poisoning, puerperal peritonitis, or some of the exan- 
themata. 

Thickening of the fibrous portion of the dura mater may 
be found as a result of chronic inflammation, either sponta- 
neous or as the result of external injury. From the identity 
of structure between this and other fibrous tissues of the 
body, it is not unlikely that this thickening is often the 
result of a rheumatic form of inflammation. 

External violence is, however, most commonly the cause 
of the change. In one case, the patient fell down stairs in 
a state of intoxication, striking the head on the steps. He 
continued in a state of insensibility for nine days, when he 
besan to show signs of returning consciousness, taking food 
and drink, but memory, judgment, and all the mental facul- 
ties were gone. Death ensued in about two years. The 
dura mater of the left hemisphere was found greatly thick- 
ened. The pia mater infiltrated with a large amount of 
serous fluid. The convolutions were atrophied, and about 
four ounces of serous fluid found in the ventricles. The 
fornix was softened and the septum lucidum entirely 
destroyed. 

Fibrinous Clots, or Thrombi, will be occasionally 
found within the sinuses of the dura mater, where they may 
have given rise to congestion of the brain, with apoplectic 
effusions, paralysis, convulsions, coma, etc. They may 
originate from injuries of the head, inflammation of the dura 
mater, pulmonary disease, etc. 



38 THE MEMBRANES OF THE BRAIN. 

Tubercular Deposits are also sometimes found in this 
membrane, appearing, however, mainly upon the arachnoid 
surface. They present the usual character of tubercle, hav- 
ing a whitish or grayish appearance, with the consistence of 
cheese, and scattered in small particles upon the surface. 
They are found in tubercular meningitis, (a disease common 
with children but rare with adults.) and in most of those 
cases of so-called acute hydrocephalus. 

Tumors of various kinds are occasionally found in the 
dura mater, including cystic, fibrous, fatty , osseous and can- 
cerous growths. The latter may cause such absorption of 
the bones of the skull, as to appear on the exterior of the 
head. 

In one case which came into the dissecting-room some 
years ago, thin bony formations of the size of a silver^ 
quarter dollar were found in the tentorium, and smaller 
ones in the falx cerebri. Nothing could be learned of the 
previous history of the case. 



2. Arachnoid and Pia Mater. 

[Notice in examination, contents of cavity of arachnoid ; serum or 
blood; if former, amount, color, odor; if blood, situation, quantity, 
fluid or coagulated ; adhesion of surfaces of arachnoid ; tubercles, 
their position, &c. ; color of membrane ; vascularity, transparency, 
or opacity. Sub-arachnoid fluid — quantity, position, color, &c. Pia 
mater — vascularity, in points and entire ; serous effusion into substance 
of; blood, &c. ; position, size, &c, of clots; granulations, (tubercles,) 
number, position, &c. ; Tumors — size, position, and character.] 

As morbid conditions of the arachnoid membrane are 
more common with its visceral layer, and as these conditions 
usually involve the pia mater, the two membranes are here 
noticed together. They will be found presenting various 



ARACHNOID AND PI A MATER. 39 

degrees of congestion after death, which will not necessarily 
be a positive indication of the extent of congestion during 
life. 

Pacchionian Bodies. Along either side of the great 
fissure may be noticed within the pia mater of adults, several 
small white bodies, varying in number and size — the Pac- 
chionian bodies. They may cause absorption and perforation 
of the dura mater, and even of the bones of the skull. 
Being looked upon as the result of mere senile changes, 
they do not indicate the presence of disease, though 
repeated congestions of the brain appear to favor their more 
rapid development. 

Inflammation of these membranes, or meningitis, is a 
very common affection, and is accompanied with an ac- 
cumulation wathin its substance or beneath its layers, of 
serum, lymph, or fibrine in various proportions. It may be 
confined to circumscribed portions, or involve a large por- 
tion of the membrane, and even extend to the spinal cord. 
Adhesions between the two surfaces of the arachnoid some- 
times result from this form of inflammation. 

Insanity in its various forms is most frequently accom- 
panied with some morbid condition of these membranes. 
In twenty-two cases of insane persons whose brains were 
inspected by Dr. Marshall, in twenty-one, serous fluid, vary- 
ing in amount from one to twelve ounces, w T as found in the 
ventricles, and in seventeen of these twenty-one cases, similar 
effusion was found in the sub-arachnoid space, or within the 
substance of the pia mater. While red injection of the 
membrane was found only in four cases, yet other conditions 
— the effusions, etc. — were evidently the result of previous 
inflammation. In nine cases were the arteries of the brain 
opaque, thickened, steatomatous, or ossified ; conditions 



40 THE MEMBKANES OF THE BRAIN. 

highly favorable for deranging the capillary circulation of 
the membranes or of the brain.* 

The following statement gives the principal morbid changes 
of these membranes which have been found in cases of 
insanity : 

1. Injection, more or less intense, of the pia mater, giving 
a red or scarlet appearance ; or, where infiltrated with serous 
fluid, presenting a pale gray color and increased in thickness. 

2. The arachnoid (the visceral layer) becomes opaque and 
thickened, resembling the dura mater or macerated parch- 
ment. 

3. The meningeal injection may terminate in serous effu- 
sion, either from the free surface of the arachnoid into the 
sub-arachnoid tissue, (pia mater,) or from the choroid plexus 
into the ventricles. 

4. Albuminous exudations may be found upon the free 
surface of the arachnoid of the dura mater, covering its 
whole extent, or confined to definite portions. 

5. Adhesions of the two surfaces of the arachnoid may 
rarely be found. It is most common in the great fissure, 
and has been found in the ventricles. 

6. Blood may be effused upon the surface of the arachnoid 
or in the substance of the pia mater. 

Serous Effusion. As has been already intimated, this 
may be found either in the cavity of the arachnoid — between 
the reflected and visceral layers — or within the ventricles. In 
the former position, the quantity is never large, while in the 
latter, it may amount to twelve or sixteen ounces, and be 
present for many years. When in such large quantity, there 

* Morbid Anatomy of the Brain, in Mania, &c," by Andrew 
Marshall, M. D. 



ARACHNOID AND PIA MATER. 41 

will be great distension of the ventricles and thinning of the 
corpus callosum and fornix, with destruction of the septum 
lucidum, as well as more or less separation of the cranial 
bones. It is only in children and before the bones of the 
head have become united, that such large accumulations are 
possible, as at a later period, from the unyielding condition 
of the walls of the skull, the presence of a single ounce, par- 
ticularly if suddenly formed, would produce death. In all 
cases, the danger to life will be in proportion to the rapidity 
of the formation ; a very slow and gradual accumulation 
permitting either of an expansion of the cranial bones, or a 
gradual absorption of brain substance, thus preserving an 
approximation to the normal pressure on the brain tissue. 

Serous effusions, like sanguineous, are generally the result 
of over distension of the cerebral vessels, either from me- 
chanical obstruction, or a weakened condition of the coats of 
the vessels, with increased force in the action of the heart. 
It generally attends tubercular meningitis, and may be 
favored by an anaemic condition of the system. The symp- 
toms during life, attending a rapid effusion of serum, are not 
so readily distinguished from those of sanguineous effusion, 
as to enable us to pronounce with certainty in any given 
case as to the cause of the cerebral pressure. 

Sanguineous Effusion — Apoplexy. Effusions of 
blood may be found between the bones and dura mater ; be- 
tween the two layers of the arachnoid ; within the substance 
of the pia mater ; within the ventricles, or within the brain 
substance. Blood clots will seldom be found between the 
bone and dura mater, except as a result of mechanical injury, 
and in the majority of cases as an attendant upon fracture. 
If a fragment of the bone at the same time, be driven through 
the dura mater, then a clot may be found in the arachnoid 
cavity. But in another class of cases, where death has 



42 THE MEMBRANES OF THE BRAIN. 

resulted from blows upon the head without producing frac- 
ture of the bones, the whole surface of the brain in the 
region of the injury, and not ^infrequently in distant parts, 
after the removal of the dura mater, is found covered with a 
layer of blood, which at first sight appears to be outside of 
the membranes ; but on close examination, it is found that the 
blood is effused or infiltrated into the sub-arachnoid tissue, 
and that it has escaped from the lacerated vessels in the 
pia mater. The thickness of the layer varies. It is gener- 
ally in greater quantities at the sides and base of the brain, 
and the inferior lobes and cerebellum may be covered by it. 
It is usually thickest over the crura, the pons Varolii and 
medulla oblongata. 

In the same class of cases the blood may be also effused 
into the ventricles. These appearances are so uniformly the 
result of violence, as to form a valuable piece of evidence in 
medico-legal inquiries, to prove that such haemorrhage and 
death could not be the result of internal causes. 

In the greater number of still-born children, an exami- 
nation of the head will show a similar condition of things. 
The surface of the cerebrum generally, with sometimes that 
of the cerebellum, will be found covered with a layer of coagu- 
lated blood effused into the pia mater, while the ventricles 
will often be filled with clots. Where the history of the 
case is not known, it might at first be suspected that death 
was the result of violence inflicted after birth. Violence has, 
to be sure, been the cause of death, but it is such violence as 
attends a protracted case of labor, with, perhaps, a large head, 
and a contracted pelvis of the mother. The wonder is, that 
from the great pressure to which the head is subjected during 
labor, that so few children are still-born or do not dLe soon 
after birth, from rupture of the cerebral vessels. 

Effusions into the ventricles, may also be frequently the 



ARACHNOID AND PIA MATE II. 43 

result of external violence. The pia mater, the vascular 
membrane of the brain, we find carried into these cavities 
bv means of the velum interpositum, which forms the roof 
to the third ventricle, while its borders extend into the lateral, 
forming the choroid plexuses. The effused blood may, there- 
fore, extend along this membrane into the cavity of the 
ventricles. 

Again, blood may be effused in any portion of the brain 
substance, constituting true sanguineous apoplexy. Certain 
parts are much more frequently the seat of these effusions 
than others. They are more common in the striated bodies 
or optic thalami — probably from the greater vascularity of 
those parts — but may be found in the corpora quadrigem- 
ina, the pons Varolii, the crura cerebri, or in the cerebral 
hemispheres, and occasionally in the cerebellum. The symp- 
toms during life will vary according to the location of the 
effusion ; when in the pia mater, or in other words, outside 
of the brain, paralysis will seldom attend, though the coma 
may be profound, Avith relaxation of the muscular system and 
sometimes convulsions. When the haemorrhage is in the 
optic bed or striated body of one side, from the decussation of 
fibres in the medulla oblongata, paralysis of the opposite side 
of the body will follow ; while if the effusion has taken 
place in both hemispheres, the palsy will be double-sided, 
though probably more complete on one side than on the 
other. 

Effusions of blood into the corpora quadrigemina, will 
most frequently be attended with muscular tremblings or 
convulsions, and probably impaired sight, with some change 
in the pupil. When in the medulla oblongata, convulsions, 
followed by palsy, deep coma, and early death ; greater fatality 
attending effusions at this point, probably, than at any 
other. When the effusion takes place in the cerebellum, 
the loss of consciousness will be very temporary ; there may 



44 THE MEMBRANES OF THE BRAIN. 

be relaxation of muscles without palsy or loss of sensibility, 
and, it is said, frequent vomiting. 

The amount of blood effused is subject to trie greatest 
variation. Clots may be found as large as a lien's egg, or 
smaller than a pea. Indeed, violent apoplectic attacks, 
ending in death, may occur, where the most careful exami- 
nation will fail to detect any effused blood, death being the 
result of extreme congestion of the membranes. On the 
other hand, the presence of a clot is not necessarily fatal, 
evidence being abundant that they may be so far re-absorbed 
as to be followed by at least partial recovery. 

The following cases will serve to illustrate these several 
conditions : 

Case I. — Sudden Death from Cerebral Congestion. 

Mr. M , aged thirty-five years, had always enjoyed good 

health. For some months previous to death, had been working very 
hard, with a good deal of anxiety, in arranging the affairs of a com- 
pany of which he was secretary. On the evening previous to his 
attack, he retired at eleven o'clock, well and in good spirits. At 
three o'clock A. M., his wife was wakened by his heavy, stertorous 
breathing, attended with slight convulsive movements of the limbs. 
In less than a half hour he was dead. The post-mortem showed the 
heart, lungs, and abdominal organs to be in a perfectly healthy con- 
dition, while the most careful examination of every portion of the 
brain failed to expose the least effusion of blood. The ventricles and 
sub-arachnoid space contained a moderate amount of serum, while the 
vessels of the pia mater were strongly engorged with blood. 

Case II. — Apoplectic Attack, followed by Death in Three Days ; Clot 
found in Thalamus. 

Mr. J , aged sixty-one, a butcher, abstemious in his habits 

but plethoric in temperament, was suddenly stricken down with an 
attack of apoplexy, which left him with paralysis of the right side of 
the body, with impaired speech and memory. He gradually and 
almost entirely recovered. Ten months after, while in the street, he 



ARACHNOID AND PIA MATER. 45 

fell with another attack. He partially recovered consciousness, but 
had complete palsy of the left side, and died in three days. Here, the 
post-mortem revealed excessive congestion of the pia mater, and a 
large clot, the size of a hickory nut, in the right optic thalamus. In 
the left thalamus was a distinct trace of a clot, (nearly absorbed, 
however,) which had undoubtedly been effused in the attack ten 
months previously. 

Case III. — Apoplectic attach, followed by Hemiplegia, and Death in 

Five Years. 

Charles E. "\V , at the age of forty-seven had a sudden apo- 
plectic stroke, in -January, 1867, followed by partial paralysis of right 
side. In May following, he had a second attack, which greatly 
increased the hemiplegia, impaired the articulation, and weakened the 
memory and intellect. His general health and strength gradually fail- 
ing, he died August, 1872, five years after the original attack. 

Post-mortem revealed a greatly thinned and dilated condition of the 
walls of the arteries of the base of the brain and the remnants of the 
original clot imbedded in the left optic thalamus, the brain substance 
around being of a dark color and much softened. From the appear- 
ance of the dark, ragged remnant of the clot, it must have been 
originally of about the size of a robin's egg. 

Case IV. — Death from Congestion, with Serous Effusion and 
Softening. 

Mr. F. H , aged thirty, had an attack of brain fever at twenty- 
three, followed by attacks of severe pain in the head, recurring every 
few days, weeks or months. These attacks were accompanied with 
slight convulsive symptoms and delirium, the pain being of a most ex- 
cruciating character, and lasting from a few hours to two or three days. 
The attacks were gradually increasing in severity, but without any 
impairment of the faculties of the mind. On a Saturday night, he was 
brought home with one of his worst attacks. When I first saw the 
patient on Sunday evening, I found him in a half-delirious, stupid con- 
dition, yet when roused up, giving satisfactory answers to questions, 
but immediately sinking into his former condition, and every one to five 
minutes starting suddenly up and, with staring eyes and distorted face, 
uttering piercing shrieks and screams, and calling to those around to 
shoot him, split open his head with a hatchet — anything to release him 
from his sufferings. These paroxysms would sometimes be followed by 



46 THE MEMBKANES OF THE BRAIN. 

a convulsive action of the diaphragm and abdominal muscles, ending in 
his sinking into the same dull, stupid condition as before. In the inter- 
val of calm, the respiration was remarkably slow and feeble, with a 
slow irregular pulse of forty beats to the minute. These symptoms 
becoming gradually worse, he sank into a comatose condition early 
Tuesday morning, expiring at daylight, sixty hours after the com- 
mencement of the attack. 

The post-mortem, revealed greatly enlarged Pacchionian glands, with 
extreme thinning of the skull over the same. The pia mater was con- 
siderably congested. Upon turning the brain back for removal from 
the base of the skull.- there was a sudden gush of water from the ven- 
tricles, sufficient of which was secured to show that the quantity could 
not have been less than two ounces. Upon opening the lateral ventri- 
cles, these cavities were found unusually large from distension by the 
fluid, while the septum lucidum and fornix were found in a soft, pulpy 
condition, the former being complete^ broken down and detached 
from the corpus callosum above. The gray portions of the corpora 
striata were also softer and more easily broken up than was natural. 

The appearance presented by a clot, as well as the brain 
substance immediately around it, will vary according to the 
time the patient survives the attach. When death follows 
in a few days, the clot will have a soft, blackish appearance ; 
after a month or six weeks, it becomes firm, and assumes a 
deep brown color, and at a still later period, it becomes still 
more firm, and of a pale red tint : lastly, it may become 
entirely absorbed. Peculiar changes also take place in the 
brain substance immediately around the clot, which vary 
according to the time intervening between extravasation and 
death. The portion immediately in contact with the clot is 
generally of a dark red or wine color, or, at a later period, 
of a chocolate brown, and of a soft, pulpy consistency. Ex- 
terior to this, the color is paler and of an orange tint, and 
still further on, of a bluish- white or yellow. The change in 
structure and consistence of the brain, immediately around 
the clot, constitutes one form of softening soon to be noticed. 



PATHOLOGICAL CONDITIONS. 47 



Section HI. OF THE BRAIN. 

[Notice before removal — size ; form ; symmetry ; space between 
surface of brain and calvarium. After removal — parts at base, their 
size, symmetry, color on surface, infiltration with serum or blood. Re- 
moval of pia mater — degree of adhesion; appearance of convolutions; 
color ; consistence ; effect of stream of water. Ulcers — condition of 
brain around. Sloughs— relation to membranes, condition of brain 
around. Deposits ; tumors, wounds, etc. After section, notice breadth 
and character of gray portions of convolutions; color, vascularity, etc. 
Consistency — softened or hardened; of white substance; color. Blood- 
'< — number and size of red points in different portions. Extrava- 
sation of blood — its situation; fluid or coagulated; amount or size of 
coagulum ; eolor, etc. Cavities in brain substance ; their number, shape 
and contents. Blood, purulent, or fluid ; its quantity and color. Condition 
of brain around ; cicatrices ; wounds ; adventitious substances, as tumors, 
calcareous masses, tubercle cancer, etc. Lateral ventricles — note any 
difference in the two ; contents ; amount of serum or blood. Choroid 
plexus — pale or congested ; cysts ; calcareous bodies ; their size and 
situation. Lining membrane of ventricles ; its vascularity, roughness, 
opacity, etc. Septum lucidum — entire or lacerated ; consistence. 
Fifth ventricle — size, contents, etc. Third ventricle ; contents. Com- 
missures — their condition ; middle, broken or double. Optic thalami and 
corpora stria ti — size, symmetry ; character of surface and interior ; if 
softened, extent; extravasation of blood, etc. Condition of pineal gland ; 
corpora quadrigemina ; valve of Vieussens, etc. Medulla oblongata — 
degree of adhesion of membranes ; softening, exact locality of; condition 
about origin of nerves ; appearance upon section. Fourth ventricle — 
contents ; condition of floor, etc. Cerebellum — examine with same care, 
and note same points as in cerebrum.] 

Inflammation. Acute inflammation of the brain sub- 
stance is a rare disease, except as the result of mechanical 
injury. In such cases, the disease is generally quite cir- 
cumscribed, being confined to the immediate region of the 
injury. The brain becomes very vascular, acquiring a red 
color, which, at a later period, changes to a brown or green- 
ish hue, and becomes much softer than natural. 

If a foreign body be lodged in the brain, as a piece of 
bone, or a bullet, then the inflammation is likely to result 
in an abscess, which will give rise to head-ache, delirium 
with intolerance of light, succeeded by convulsions, coma 
and death. 

Subacute, or chronic inflammation of the brain, is much 



48 PATHOLOGICAL CONDITIONS. 

more common, yet is accompanied with pathological changes 
similar to those of the acute form. At first, the inflamed 
portion becomes red and congested, the color gradually 
changing to a crimson, purple, brown, or claret color, with 
more or less change of consistence. 

The symptoms attending inflammation of the brain sub- 
stance, or cerebritis, are not readily distinguishable from 
those of meningitis ; indeed, in most instances the two dis- 
eases are, to a certain extent, combined'; as, from the vas- 
cular connection between the brain and pia mater, there 
might be a ready extension of inflammation from one to the 
other. When, however, there is any sudden perversion of 
the sense of vision or hearing ; or if there are convulsions, 
affecting mainly one side of the body ; or if coma succeeds 
the convulsions and is accompanied by one-sided paralysis, 
we may expect to find evidence of inflammation of the cere- 
bral substance, with possibly that of the membranes also. 
It is a fact to be borne in mind, however, that while in 
typhus and typhoid, and perhaps some other forms of fever, 
we may have symptoms strongly resembling those of idio- 
pathic inflammation of the brain or its membranes, still the 
post-mortem will reveal no trace of any such morbid con- 
dition. 

Softening. To be able to recognize readily any change 
in the consistency of the brain, clear ideas must first be had 
of the normal density of this organ. This may be obtained 
from an examination of the brain of some of the lower 
animals — as the sheep or ox — that has been killed in a state 
of health. We shall then find that the brain presents suffi- 
cient firmness to permit of its being handled without rupture 
of its substance, and to allow of its being sliced into thin 
sections which will support their own weight. The gray 
portion is somewhat softer than the white, yet the fibrous 
character of the latter, becomes apparent only after hard- 



OF THE BRAIN. 49 

ening in alcohol. If put into pure water, it continues 
unchanged for eight or ten hours, and without any portion 
becoming dissolved, or rendering the water any degree turbid. 
The consistence of the brain varies, normally, at different 
periods of life. In the foetus and at birth, its softness 
approaches to semi-fluidity. From this to the fifteenth or 
twentieth year, it gradually acquires the firmness of the brain 
of the adult. 

Softening, one of the most common variations from 
the normal condition, is generally a mere result of in- 
flammation of a chronic or sub-acute form, accompanied 
with a fatty degeneration of nerve substance. Under the- 
microscope, the change is seen to consist in a disintegration 
of the nerve fibres, the medullary substance breaking up- 
into large masses, and undergoing fatty metamorphosis. It 
may take place either on the external surface of the organ, 
or in the septum lucidum and fornix, the corpora striata, or 
optic thalami of the ventricle, the central parts of the 
hemispheres, the cerebellum, or the crura cerebri, in the 
order mentioned. 

While this change is usually the result of inflammation,. 
as already mentioned, it may accompany or succeed the fol- 
lowing morbid conditions of the organ : 1. It may be the 
result of congestion of the vessels of some portion of the- 
brain. In this case, the softened portion is reddish, crimson, 
or brown in color. 2. It may follow the effusion of blood t 
in apoplexy. The softened portion is then of a brownish, 
color, or, if considerable time has elapsed, it may be of a 
dirty ash color, tending to green. 3. It may accompany or 
follow the process which terminates in serous effusions. It. 
is then of a milky-white color. 4. It may take place in the- 
brain substance immediately around tumors, when its color- 
may present a variety of tints. 

Among the causes tending to induce this condition of 

4 



50 PATHOLOGICAL CONDITIONS. 

the brain, may be mentioned a diseased state of its blood 
vessels, or their obstruction by fibrinous clots; constitutional 
syphilis ; excessive mental labor, or frequently repeated 
epileptic convulsions. The consistency will be found to 
vary from a slight change from the normal condition, to that 
of a soft, pulpy, or even cream-like condition. 

The symptoms accompanying softening of the brain, pre- 
sent a considerable variation. Among the more prominent, 
may be mentioned an unsteady or tottering ' gait, partial 
palsy, thick and inarticulate speech, feeble memory, disor- 
dered intellect, dull pain or heaviness in the head, frequent 
drowsiness, formication, numbness or rigidity, or occasional 
involuntary contraction of the muscles of the upper ex- 
tremities. 

Abscess of the brain, differs from softening, to which it 
may have some points of resemblance, in the purulent mat- 
ter being contained in an irregular cavity, lined with a more 
or less distinct membranous cyst. Flakes of lymph are 
frequently found in these abscesses, giving the matter much 
the appearance of that contained in scrofulous abscesses, and 
they are most commonly found in subjects who present the 
usual symptoms of the strumous diathesis. 

While these collections are unquestionably often the 
result of inflammation, yet it has been claimed that they 
may result from previous disease of a suppurative character 
in the lungs, and perhaps other organs, the purulent matter 
being taken up by the veins and carried into the general 
circulation, and finally deposited in the substance of the 
brain. Abscesses may be found in any portion of the brain 
substance, or the purulent accumulation may be found 
between the bone and dura mater, or between the two layers 
•of the arachn6id. In the latter cases, the disease may 
generally be traced to caries of some of the bones of the 
head, as of the petrous or mastoid portions of the temporal, 



OF THE BRAIN. 51 

or of the bones of the nasal cavity, involving the cribriform . 
portion of the ethmoid. 

Again, abscesses in the brain may result from external 
violence, as from a blow or fall upon the head. It is 
remarkable, that in these cases, some months may elapse 
between the date of the injury and death.. 

Hardening. Induration of the cerebral substance, is a 
condition not readily distinguished during life from that of 
softening, the two states being accompanied by symptoms 
of a similar character. Dr. Jones, who has charge of the 
male department of the Pennsylvania Hospital for the In- 
sane, and has had many opportunities for examining the 
brains of insane patients, tells me that he found hardening, 
nearly as frequently as softening, in these cases, and never 
could tell beforehand, with certainty, which condition might 
be present. 

In hardening of this organ, its density may be increased 
to that of boiled white of egg, or it may approach in con- 
sistence to that of a brain that has been hardened in alcohol, 
losing much of the sticky, adhesive character when broken 
up by the fingers, which marks the brain substance when in 
its normal state. The cause of the change is not well known, 
yet it is conjectured to be one of the results of inflammation, 
inasmuch as it is generally found with its capillaries greatly 
loaded with blood, while more or less fluid is found beneath 
the arachnoid and in the ventricles. The induration may 
affect the greater part or even the whole of the cerebral 
mass, or may be confined to particular portions or regions. 

In a case recently examined for Dr. Toothaker, of this 
city, where insanity of some years' duration, and finally 
death, had followed a severe injury of the head, the brain 
was found so hard as to permit of fracture in the direction 
of the fibres, thus readily tracing their course. 



52 PATHOLOGICAL CONDITIONS. 

The symptoms that have most frequently been observed 
to accompany this change are, defect and gradual loss of 
memory, apathetic indifference, slight difficulty of articula- 
tion, followed by loss of sexual desire, partial palsy, fatuity, 
wasting and death. 

Extreme induration is often found in the brains of idiots. 
The whole organ may be found resembling in color and 
density boiled white of egg, or even cheese. The cerebral 
substance is shrunken, dense, and apparently quite void of 
vessels. 

Hypertrophy of the brain, is a condition in which there 
is usually increased hardness as well as increased volume, 
and is distinguished by flattening of the convolutions, nar- 
rowing of the ventricles, and a remarkable dryness of the 
whole organ with its membranes, the change involving both 
the cerebrum and cerebellum, and accompanied with an 
increase of weight, all indicating increased nutrition, or the 
deposit of new matter in the tissue of the brain. Thinning 
of the cranial bones may attend this condition, increased 
internal pressure resulting in their partial absorption. 

The causes of this form of disease are not generally under- 
stood. The symptoms, though always present, are not 
uniform. Among them may be mentioned intense head- 
aches, a weakened or perverted state of the intellectual 
faculties, fits of giddiness, accompanied with stupor ; finally, 
convulsions, with perhaps loss of sensation and motion, the 
patient being unexpectedly cut off by an epileptic attack. 
The disease has not been observed in persons over fifty. In 
most cases, the patients were between twenty and thirty. 
In one instance, however, it was developed in a young 
girl of thirteen. Lead poisoning would seem to be 
an exciting cause, it having, in several instances, been devel- 
oped in painters and manufacturers of white lead. 



OF THE BRAIN. 53 

Atrophy. In this condition, there is found a general 
diminution of the volume of the brain, and especialty of the 
convolutions. The latter are shrunk, narrow, and sometimes 
softened, while the sulci are large and open, the brain 
receding from the skull, and the pia mater greatly injected 
with serous fluid, giving the appearance of a jelly-like 
investment to the whole brain. 

The brain substance is at the same time soft, the ventri- 
cles enlarged and filled with fluid, while a large amount of 
serum will flow from the subarachnoid space at the base of 
the brain, and from the spinal canal. 

While this condition of the brain might be looked upon as 
a result of pressure from the accumulated serum, the absence 
of the usual symptoms of hydrocephalus, with the known 
history of these cases, renders it quite probable that the 
change commences as an actual loss of brain substance, the 
place of the latter being supplied with serous fluid. 

Resulting from atrophy of the brain, there will often 
be found an increased thickness of the cranial bones, this 
being another conservative effort of nature to preserve the 
normal support and pressure upon the brain. 

Atrophy of the brain is sometimes found in old age and in 
various enfeebling diseases, where all the organs suffer more 
or less waste from improper nutrition, but it is so frequently 
found with drunkards, especially those who have died with 
delirium tremens, that this condition may, in the large 
majority of cases, be considered as the effect of intem- 
perance. 

Several forms of atrophy may also be observed. It may 
be confined to some portion of the convoluted surface, or to 
one of the striated bodies or optic beds. Atrophy of the 
optic tracts, or nerves of one or both eyes, is not unfrequently 
associated with loss of sight from amaurosis. 



54 PATHOLOGICAL CONDITIONS. 



Tumors of the Brain. 

The brain, like other parts of the body, is subject to mor- 
bid growths of a great variety of forms. The symptoms of 
tumors in the brain, in many points, present such resem- 
blances to other forms of disease, that it is usually the post- 
mortem alone, that will determine the fact of their presence 
or character. It may be said in general, however, that the 
effects of morbid growths in the brain will vary according : 

1. To the changes in the surrounding cerebral substance. 

2. To the size of the growth ; and 3. To the position of the 
brain in which it may be developed. 

1. The changes induced in the brain substance surrounding 
tumors are usually, first, derangement of the circulation, 
and second, as a result of this, effusion of serum, or finally, 
softening of a greater or lesser amount of contiguous cerebral 
substance. Head-ache, with epileptic attacks, loss of 
memory, irregular contraction of the muscles and partial 
paralysis may accompany the vascular derangement, while 
as softening or pulpy destruction supervenes, a general 
aggravation of all the symptoms will follow, ending in death, 
either with coma or by a sudden apoplectic attack. 

2. Tumors of the brain of a small size, may be found 
after death from other causes, that have evidently produced 
no symptoms during life; and in other instances, they have 
induced no change until a few days before death, in which 
cases, the convulsions, paralysis and coma which precedes 
this result, must be attributed to the vascular disturbance 
in the surrounding brain tissue. 

3. The position of the tumor, will modify to some extent 
the character of the symptoms manifested. When in the 
anterior lobes, loss or impairment of speech is said to attend. 
While, when in the corpus striatum, the motions of the legs 
and arms are disordered. 



OF THE BRAIN. ' 55 

The following are the more commonly recognized tumors 
of the brain : 

Adenoid, or Glandular-like Tumors. These are 
generally described as resembling an enlarged lymphatic 
gland, both in color and density. They may vary in size 
from a filbert to that of an orange. There may be a single 
growth of this kind, or several, and they may be found in 
any part of the brain. 

Tubercular or Scrofulous Tumors. Under this 
head may be placed certain bodies of a white or pale yellow 
color, firm, like soft cheese, sometimes granular and friable, 
and consisting chiefly of a large proportion of albuminous 
matter. They may be found first, as one or more indi- 
vidual masses of considerable size ; or second, sometimes as 
many minute rounded bodies, distinct and separate from 
one another. 

In examining the head of a hydrocephalic child of four 
years, with Dr. von Tagan, we found attached to the under- 
side of the middle lobe of the left hemisphere, a body of a 
white cheesy consistence, and of the size of half a hen's 
egg. Connected with the cerebellum, was another tumor of 
the same character, but smaller in size.* 

Tubercular masses of this kind, may be found on the 
surface, or imbedded in the substance of any portion of the 
cerebrum or cerebellum. 

The second form of tubercular deposits, are confined almost 
wholly to the gray matter of the surface. In one case, 
over two hundred of these bodies were found scattered 
through the gray matter of the cerebrum and cerebellum, 
of the size of a pea or bean, and of a pale yellow or bluish 
color. When cut open, the interior of the bodies was found 
to resemble boiled potatoes in consistency. 

* See No. 1386, Case T, €olWe Museum. 



56 PATHOLOGICAL CONDITIONS. 

This form of disease is confined principally to children. 
Of thirty cases collected by Dr. P. H. Green, of London, 
all were between the ages of nineteen months and twelve 
years. 

Adipose Tumors. Under this name, has been described 
a peculiar and quite rare form of disease of the brain, in 
which either some portion of the brain itself, or growths 
attached to or imbedded within the cerebral substance, pre- 
sent a fatty appearance, which by some has been denomi- 
nated lardaceous degeneration. The exterior of the tumor 
is smooth, of a yellow color, and the interior composed of 
adipose matter of ash color, and semi-solid consistency. 

Cholesteroma. This is another rare form of tumor of 
the brain, consisting of white pearl-like, glistening bodies, 
varying in size from that of a pea, to a walnut or small 
orange. They are found mostly at the back of the brain, 
and in the subarachnoid tissue. When examined chemically, 
the substance of these tumors is found to consist almost 
wholly of cholesterin. 

Cartilaginous Tumors. These are often spoken of as 
scirrhus in their nature. They may be described as irreg- 
ular in shape, sometimes lobulated, the interior yellowish 
in color, of a cartilaginous hardness, and arranged some- 
times in streaks or bands, in other cases, in rounded masses. 
At a more advanced stage, from softening of the interior, 
cavities begin to form, which are filled with a semi-fluid or 
jelly-like substance. Death will generally ensue before this 
process is far advanced. 

Calcareous or Bony Deposits. Osseous formations 
are not unfrequently found connected with the membranes 
of the brain, but rarely, if ever, with the brain substance. 



OF THE BRAIN. 57 

Calcareous deposits, on the other hand, have been found in 
almost every part of the brain. In the brain of an idiot 
of sixteen, the pons Varolii, crura cerebri and cerebellum, 
contained so much earthy matter, as to give difficulty in 
cutting with a knife, (Sir E. Home.) In the brain of a 
man who had long suffered from acute pain in the head, a 
hard plaster-like concretion was found as large as a filbert. 
These bodies are, therefore, not to be looked upon as 
genuine bony formations, but rather as an infiltration of 
chalky substance into the brain tissue. Of the same nature, 
are the calcareous deposits found in the pineal gland, which, 
although very constantly present after the age of eight or 
ten years, can hardly be considered as normal products, 
although it is well established that they exert no influence 
on the functions of the brain. 

Encysted Tumors, Hydatids. A variety of tumors 
of the encysted form have been found in the brain by dif- 
ferent observers, varying in size from a pea, to that of an egg 
or orange. Their contents also, have presented a great 
degree of variation. While some have been filled with the 
cheesy substance of the ordinary steatome, others have con- 
tained blood, a jelly-like, or even a limpid watery fluid. 

It has been claimed by some, doubted by others, that the 
animal hydatid, the cysticercus, has been found in the 
human brain. Having unquestionably been observed in the 
eye, the heart, and other parts of the body, it may also, 
possibly, sometimes be found in the brain. This curious 
animal is now known to be but the larval form of one of 
the cestoid entozoa, the Tamia solium. Its position in the 
brain, can only be accounted for, by supposing that the 
embryo, which in its first stage is very minute, by piercing 
the coats of the stomach, into which the egg has been taken 
with the food, enters a blood vessel, and being carried into 
the brain, lodges in some of the capillaries, the walls of 



58 PATHOLOGICAL CONDITIONS. 

which it penetrates. Entering thus the brain substance, 
it develops into the second larval form, which consists of a 
small bag or cyst, filled with a limpid fluid. Developed 
within the cyst, yet capable of being thrust out, is the 
head, which presents four sucker-like processes, surrounded 
by a circle of minute hooks, which give it the power of 
active migration through the tissues. In the pig, the 
presence of these cysticerci constitutes measly pork, which 
if taken into the stomach in a raw State, the contained 
larvae at once develop into the perfect worm, the Tcenia 
solium. 

Blood Cysts, though not common, have been found in 
the brain. They consist of a membranous c)^st, which may 
be lobulated or contain smaller cysts, the inner surfaces of 
which are lined with a vascular membrane, from which 
escapes a bloody fluid. 

Cancerous Tumors may be found in any portion of 
the brain, and may present the several varieties of these 
malignant growths, including fungus hcematodes. While 
they are generally secondary with similar tumors in other 
parts of the body, they may be primary in their origin. 
They may acquire such a development as to cause absorption 
of both the dura mater and skull, and thus appear upon the 
outside of the head. In fungus hcematodes, the enclosed 
substance consists of soft spongy matter, of a brain-like 
consistency, divided into lobular masses, of a reddish shining 
aspect. They are mainly found in young subjects, some- 
times in adults. 

Melanosis. This form of morbid growth is occasionally 
found in the human brain. The middle lobe of the left 
hemisphere of the brain of a subject in the dissecting-room, 
was found to be attached to the dura mater by a melanotic 



OF THE BRAIN. 59 

mass, resembling the dark bodies frequently found around 
the bronchial tubes. Its attachments were such as to render 
it doubtful whether it had its origin in the brain or in its 
membranes. The gray substance of the brain of persons 
who have suffered malarial diseases, is sometimes found 
presenting a blackish appearance from the dark pigment 
within its substance, or within the pia mater. 

Syphilitic Tumors are occasionally found in the brain, 
situated near its surface. Their characters are not such as 
to permit of their ready recognition, except when associated 
with syphilitic growths in other parts of the body. They 
may vary in size from a pin's head to a cherry. They pre- 
sent a rounded or irregular form, a yellow color, and are 
composed of spindle-shaped or round cells, which may 
undergo a cheesy degeneration. 

Obstruction of Cerebral Arteries. Patients suffer- 
ing from endocardial inflammations, or from aneurism of the 
arch of -the aorta, or from any cause having fibrinous 
deposits forming in the heart, are liable to have the same 
washed along the carotids, and thus carried into the vessels 
of the brain, thereby deranging the circulation through 
this organ. The symptoms resulting, are generally those of 
apoplexy. Hemiplegia, with or without loss of consciousness, 
follows. Softening of the cerebral substance follows as a 
result of the accident, and it is not impossible but that the 
presence of these bodies is the general cause of this structural 
change of the brain. 

The position of the embolus, in fatal cases, is usually 
in one of the middle cerebral arteries ; these vessels being 
in a more direct line with the internal carotids. They may 
lodge, however, in the vertebrals or basilar, yet through the 
circle of Willis, the several parts of the brain will still receive 
a partial supply of blood. 



60 PATHOLOGICAL CONDITIONS. 

Atheromatous Degeneration, and Calcification 
of Cerebral Arteries. The coats of the arteries of the 
brain in old people, are liable to become infiltrated with 
atheromatous and calcareous matter to such a degree, as to 
render them rigid, and inelastic. 

While the arteries of the base of the brain, as the basilar, 
the cerebrals, or the communicating of the circle of Willis, 
are more liable to this change, it may involve the smaller 
branches as well. The increased thickness of the coats of 
the vessels, results in a diminution of the calibre, while they 
are enlarged in external circumference. 

Resulting from this state of the vessels, we shall have 
disturbed circulation, followed by effusion, and in some 
cases by atrophy of the brain. Attending this condition, 
are frequent attacks of stupor and insensibility, lasting 
for several hours or even days. 

Again, from the weakened condition of the coats of the 
vessels in these cases, we may have an aneurism resulting, 
the walls of which suddenly giving away, death from 
haemorrhage speedily follows. 



Section IV. OF THE SPINAL CORD. 

[Notice in examination. 1. Vertebral. — Condition of several parts; 
caries, etc. 2. Vertebral Canal. — Proportion to cord; contained fluid; 
serum, pus or blood ; amount, etc. ; condition of spinal veins. 3. Mem- 
branes of cord. — Bulging of any part: thickening; congestion; morbid 
growths, etc. ; fluids within ; amount, color, etc. 4. Spinal cord. — 
Weight ; size ; condition of fissures ; of interior, as seen on section ; 
softening; exact point of ; roots of nerves; pressure upon, etc.] 

From the continuity and identity of structures, the spinal 
cord is subject to essentially the same diseases as those of 
the brain. 

1. The Membranes. 

Inflammation of the latter may exist alone, or in con- 
nection with that of the membranes of the brain, constituting 



OF THE SPINAL CORD. 61 

cerebrospinal meningitis. Inflammation of the dura mater 
is an uncommon occurrence. The inflammation in spinal 
meningitis is almost wholly confined to the pia mater, this 
being the more vascular of the membranes. A pale reddish, 
or sometimes purple color, with a bloody jelly-like infiltration, 
characterizes the earlier stage, while at a later period the 
membrane presents a greyish or dirty yellow appearance, 
from the presence of a thick pus-like substance covering 
the surface. Such inflammations may be either idiopathic, 
rheumatic or traumatic in their origin. 

In spotted fever the inflammation extends to the pia mater 
of the base of the brain, and is remarkable from the epidemic 
form which it sometimes assumes. 

Tubercular deposits, as well as tumors of various kinds, 
may be found connected with the spinal membranes, so similar 
to those described with the cerebral membranes, as not to 
require separate notice. 

Serous effusion may be found in the spinal canal, 
in the same cases when it exists in the cranial cavity, and 
may be either a diffusion of fluid through the sub-arachnoid 
space, that has been effused in the brain, or it may originate 
from the membranes of the cord itself. The fluid may be 
either between the vertebrae and dura mater, or between 
the latter and the pia mater. 

A peculiar form of dropsy of the spine is sometimes found, 
congenital in its nature, and accompanied with a deficiency 
in the spinal column, by means of which a cleft remains in the 
arch of one or more of the vertebrae; hence fch ime, Spina 
bifida, as applied to this disease. The effusion in these 
cases, taking place before the vertebrae are fully developed, the 
pressure from within prevents the final closure of the canal 
posteriorly; when, from want of support at that point, the 
membranes and covering tissues, yielding to the pressure from 



62 PATHOLOGICAL CONDITIONS. 

the accumulating fluid, gradually protrude at that point, 
producing a rounded fluctuating tumor. The disease is more 
frequently found in the lumbar region, although it may occur 
in the dorsal or cervical, and in some cases may involve the 
whole spinal column. 



2. Spinal Marrow. 

Inflammation of this structure, {myelitis,) presents the 
same character, and may be followed by the same results as 
inflammation of the brain. From the distension and eno-orge- 
ment of the capillaries of the inflamed part, a bright red 
color may be presented, not only on the surface, but in the 
substance of the cord when exposed by division. Blood 
may also be found effused in the substance of the cord, or 
between its membranes, or between the bony walls and the 
dura mater. 

Softening of the spinal cord, may arise either spon- 
taneously, or as a consequence of injury. When spon- 
taneously taking place, a large portion of the cord may 
be involved. The appearance presented, is most usually 
that of a soft pulpy mass, which easily breaks down upon 
the opening of the membranes. When the result of injury, 
the softening is generally confined to the portion involved 
in the original violence. 



o 



Hardening of the spinal marrow, (sclerosis,) maybe one 
of the results of inflammation, yet the accompanying symptoms 
may vary so slightly from those of other forms of spinal 
disease, that the post-mortem alone, will disclose the true 
nature of the difficulty. In locomotor ataxy, the posterior 
columns of the cord are usually affected with this change. 



OF THE SPINAL CORD. 63 

Atrophy of the spinal cord, differs from hardening, in 
the shrinking which attends the progress of the disease, 
although there may be increased density, as in the former 
case. The essential peculiarity of atrophy, consists in an 
increased development of the fibrous elements of the cord, 
which by pressure, gradually destroys the elementary nerve 
constituents. This disease is confined chiefly to men of a 
middle age, and is generally the result of venereal excesses; 
muscular over- exertion, exposure to cold, &c, may also be 
exciting causes. 

Morbid Growths, of various kinds, and closely resem- 
bling those found in the brain, as well as animal parasites, 
are sometimes found in the spinal cord. 



PART II. 

THE NECK AND CHEST. 



CHAPTER I. 
OPERATION ON THE NECK. 

The parts which we may wish to examine in the region 
of the neck in a post-mortem examination, include the tongue, 
the larynx, the trachea and the oesophagus. These may be 
removed together, by first making a single, straight incision 
from the chin, down the central line of the neck to the 
sternum. Next turn aside the integument with the superfi- 
cial structures, separate the muscles of the tongue from their 
attachment to the jaw, and divide the mucous membrane of 
the floor of the mouth on either side of the tongue, when, 
with the tenaculum, the latter may be drawn down beneath 
the jaw. The neck being well extended and the tongue 
forcibly drawn down, the knife may be carried back on 
either side of that organ, dividing; the muscles and mucous 
membranes, including the palatine arches and tonsils, when 
the tongue may be so drawn down as to permit the knife to 
reach the posterior walls of the pharynx. This being divided, 
from the slight adhesion to the spinal column, the whole 
may now be drawn down and removed together, the trachea 
and oesophagus being divided at the upper end of the 
sternum. 
(64) 



OPERATION ON THE CHEST. 65 

By the use of the enterotome, the pharynx, larynx and 
trachea may be laid open from behind, which will fully 
expose their interior for careful examination. 

After the examination of the parts is completed, if it is 
desired to preserve the specimen, the cavity remaining may 
be so filled with paper or rags, as, upon the closing of the 
part, to leave little or no evidence of the absence of any 
portion. 

Through the mouth, the buccal cavity may be examined, 
when there may be noted the condition of the teeth, gums, 
tonsils, palate, etc. ; the presence or absence of ulcers on 
any of these parts, or of food or other foreign substances 
within the cavity. 

OPERATION ON THE CHEST. 

In opening the thoracic cavity for an examination of its 
contents, a straight incision may be made along the central 
line, through the skin and superficial tissues, from the upper, 
end of the sternum, to near the umbilicus. If it is desired 
to examine the abdomen at the same time, the incision may 
be carried on to the pubis ; otherwise, ending just above the 
umbilicus, a transverse cut may be carried from its lower 
end, to the border of the chest upon either side. These 
incisions being carefully carried through the muscles and 
peritoneum, the flap thus formed may be lifted and turned 
up upon the chest, and the peritoneum divided along the 
cartilages of the ribs. The integument with the pectoral 
muscles may now be dissected up together, and turned back 
as far as the union of the cartilages with the ends of the 
ribs. With the heavy cartilage knife, the former may now 
be divided near their union with the ribs ; care being 
observed not to permit the knife to pass into the chest, and 
thus injure the lungs. In aged persons, and sometimes in 
the middle aged, the cartilages will be found so ossified, as 



66 OPERATION ON THE CHEST. 

to require the use of the saw or chisel in the place of the 
knife; this being more frequently required with the first 
ribs, than with any other. The ligaments uniting the 
clavicle with the sternum, having been divided, the latter 
may be removed by commencing at the lower end, and 
separating the diaphragm from its connections to the 
sternum and costal cartilages. The sternum being now 
lifted from below, the mediastinum may be divided, this 
forming the only bond of union to the parts beneath, 
except in cases, where, from pleuritic inflammation, adhesions 
may exist between the lungs and costal cartilages. 

The sternum having thus been removed, the lungs will be 
found more or less collapsed from atmospheric pressure, 
unless adhesions be so extensive as to prevent. 

The attention may now be given to the pericardium and 
heart. By making a small opening into the cavity of the 
former, any dropsical fluid present may be removed and 
measured. This may be accomplished, by introducing the 
point of a syringe into the opening, and carefully drawing 
the fluid into the same, and then forcing it into some vessel. 
Or, it may be carefully absorbed by a sponge, and then 
squeezed out and measured. 

The heart may be removed for examination, by dividing 
the large vessels springing from its base. In examining 
the cavities, valves, &c, the right auricles should first be 
opened, by an incision along its base, another meeting this 
at right angles, thus making two angular flaps, which may 
be turned aside, exposing the interior. In opening the 
ventricle, let one incision be made parallel with, and about 
one-third of an inch from the groove in the anterior surface 
dividing the right from the left ventricle, commencing at 
the base and extending to the apex ; and another along 
the posterior groove, meeting the former at the apex, thus 
making a triangular flap, which may be lifted, exposing 
the interior of the cavity, without injury to the tendonous 



OPERATION ON THE CHEST. 67 

cords. The semilunar valves of the pulmonary artery 
may readily be exposed, by splitting open that vessel, and 
turning aside its walls. The left side of the heart may 
be examined in the same manner. 

The examination of the lungs may often be made in situ. 
Deep incisions may be made into their substance at various 
points, or portions may be removed for examination. If a 
more careful inspection is desired, or if we wish to examine 
the bronchial tubes or aorta, the whole thoracic viscera 
may be removed together. To accomplish this, divide the 
trachea and oesophagus, as they enter the chest, with also 
the branches arising from the arch of the aorta. Carry 
the hands around either lung, breaking up any adhesions 
which may be found, and then by grasping the trachea and 
arch of aorta, and dragging down upon the same, the pos- 
terior mediastinum may be divided from above downwards, 
the aorta and oesophagus divided as they pass the dia- 
phragm, and the whole of the contents of the chest thus 
removed en masse. Placed upon a large tray, they may 
now be examined in detail. The bronchial tubes may be 
best inspected from behind, laying open the passages with 
the scissors at their posterior walls. By means of deep 
incisions, extending from apex to base upon the anterior 
surface, the condition of the interior of the organs may- 
be carefully noted. 

The examination completed, all blood should be sponged 
from the cavity, the organs replaced, and any remaining 
vacancy filled with bran or saw-dust. The sternum now 
being placed in position, the incision may be sewed up. 



68 PATHOLOGICAL CONDITIONS. 

CHAPTER II. 

PATHOLOGICAL CONDITIONS. 

Section I. OF THE TONGUE. 

[Notice in examination : size ; form ; surface coated or clean ; fur- 
rowed or fissured ; marks of bites, stains ; color generally ; vesicles ; 
ulcers ; sloughs ; tumors, wounds, etc.] 

The diseases of the tongue, the appearance of which we 
-may wish to examine after death, include cancer, syphilitic 
ulcers or tubercle, tumors, hypertrophy , etc. 

Cancer is the only disease of this organ likely to result 
in death. It is said to occur more frequently in females 
than males. It may assume the various forms of this dis- 
ease, but is more frequently epithelial or scirrhus, than 
medullary. 

Syphilitic Ulcers or Tubercle, may be confounded 
with cancer, and in some instances, only a previous knowl- 
edge of the history of the case, assisted by a microscopic 
examination, would positively determine the diagnosis. 

Tumors of various kinds — encysted, fatty, fibrous and 
erectile — may be found in the substance of the tongue, or 
underneath it in the floor of the mouth. 

Ranula is a peculiar form of tumor found under the 
tongue, often attaining the size of a pigeon's egg, and filled 
with a watery or albuminous, or sometimes cretaceous mat- 
ter. The tumor is usually considered as arising from a 
dilatation of Wharton's duct, but of this there is doubt 
in some cases. 



OF THE LARYNX AND TRACHEA. 69 

Hypertrophy of the tongue is sometimes found, where, 
from an increase of the connective or areolar tissue, without 
any change in the muscular fibres, the organ has become 
greatly enlarged, so as to cause deformity of the mouth, or 
even of the whole lower part of the face. This condition 
may involve the whole or a portion only of the tongue. 



Section H OF THE LARYNX AND TRACHEA. 

[Notice in examination: 1. Contents — mucus; lymph; pus or blood; 
amount ; foreign bodies ; false membranes, etc. 2. Larynx — condition of 
epiglottis ; oedema, ulcers, sloughs, polypi ; same of superior opening 
to cavity. Ventricles — condition of mucous membranes, etc. Vocal 
Cords — thickness, color, oedema, ulcers, etc. Cartilages — condition of; 
ossification; caries, etc. 3. Trachea — contents; mucous membrane; 
cartilaginous rings: ossification of; caries; denuded of mucous mem- 
brane, etc.] 

Inflammation, ulceration, ozdema, necrosis of the cartilages, 
tumors and false membranes are the more usual pathological 
conditions of these parts that may claim the attention in a 
post-mortem examination. 

Inflammation of the mucous membrane of the larynx 
(laryngitis) and trachea, will appear as a diffused redness, 
with some thickening of the membrane, and within which 
may be traced many small, congested blood-vessels. It may 
be important to distinguish the redness of inflammation, from 
that attending the early stage of decomposition, which, it is 
an interesting fact to know, first appears in these parts. 
Immediately after death, the mucous membrane is pale, 
except in death from suffocation or laryngitis. In a day or 
two it becomes of a dusky red, which is distinguished from 
that of inflammation by the absence of congested vessels; 
the redness of decomposition, also, having a superficial filmy 
appearance, as if washed with dirty wine. 



70 PATHOLOGICAL CONDITIONS. 

Ulceration of the larynx commences in the mucous 
membrane, but may extend to the deeper parts. The more 
usual location is upon the epiglottis, or on the margin of the 
glottis and vocal cords. Impairment of the voice to a 
greater or less degree, will have attended either inflammation 
or ulceration of the vocal cords. It is to be borne in mind, 
however, that aphonia may arise from some impairment of 
the nerves of the larynx, in which case, a post-mortem 
examination will fail to reveal any morbid condition of the 
mucous membrane or vocal cords. 

Pulmonary consumption we sometimes find accompanied 
with the presence of ulcers upon the posterior walls of the 
larynx, with evidence of inflammation in the surrounding 
parts. Whether these arise from tubercles in the mucous 
membrane, or ulceration of the mucous follicles, is uncertain. 

CEdema of the larynx, is attended with great swelling 
of the mucous membrane, from serous effusion into the 
submucous tissues, and frequently attends chronic inflamma- 
tion of the parts, with ulceration. It may, however, be of 
an erysipelatous character, occurring as the result of exposure 
to infection. The surface appears red, pulpy and swollen, 
from infiltration of the submucous tissue. CEdema of the 
larynx, is confined to the parts around the epiglottis, and 
margins of the glottis, never descending below the true vocal 
cords, owing to the close adhesion of the mucous membrane 
to the fibrous structure of the cord, without any intervening 
areolar tissue. 

Necrosis of the Cartilages of the larynx, may occur 
in the advanced stage of laryngitis with ulceration. In this 
manner the epiglottis, with the arytenoid, the cricoid, and 
even thyroid cartilages may, to a greater or less extent, be 
destroyed. 



OF THE LARYNX AND TRACHEA. 71 

Abscesses may also form, where the cartilages are so 
much involved, these in some cases breaking upon the 
outside, and establishing fistulous communications through 
which air may escape during respiration. 

Tumors of the larynx, may be found first, outside of 
the cavity, imbedded in some portion of its tissues ; and 
may include encysted, fatty or fibrous tumors ; or, second, 
they may be found in the interior, springing from the mu- 
cous membrane, and resembling polypi in their form and 
structure. They are sometimes granular or cauliflower-like 
in appearance, and vary in size from a pea to a hazel-nut. 

False Membranes may be found in the larynx and 
trachea in fatal cases of croup or diphtheria. In croup, the 
membrane adheres but slightly to the mucous structure 
beneath, which will be found red and congested, but may 
form a complete tubular lining to both larynx and trachea, 
extending also into the bronchial tubes.* It is usually 
tougher in the larynx and upper portion of the trachea, be- 
coming softer and more gelatinous in the lower portion of the 
trachea and bronchial tubes. Much difference of opinion 
has been entertained as to the nature of this substance. It 
may, however, be considered as a morbid secretion from the 
inflamed mucous surfaces, in a semi-fluid form, which, in 
consequence of the presence of albuminous matter, coagulates 
upon exposure to air. 

The false membrane of croup may generally be distin- 
guished from that of diphtheria by the fact, First, That the 
latter is usually confined to the fauces, sometimes extending 
to the larynx, rarely to the trachea. Second^ That diphthe- 
ritic membrane occurs more in patches, is tougher, is more 
directly incorporated with the mucous surface beneath, and 



* See No. 1295, Case R, College Museum. 



72 PATHOLOGICAL CONDITIONS. 

is removed with more difficulty. Third, A microscopic ex- 
amination shows the membrane to be composed mainly of 
fibrine in a fibrillated condition, with granular corpuscles 
and pus cells. 



Section HI. OF THE PHARYNX AND (ESOPHAGUS. 

[Notice in examination: displacements; their cause, as by tumors, 
etc.; dilatation; contraction or stricture, seat of ; calibre at stricture; 
above, below; condition of mucous membrane ; ulcers, etc. Contents of 
oesophagus ; food, foreign bodies, wounds.] 

These parts are liable to inflammation, ulceration, stric- 
ture, dilatation and new growths. 

Inflammation of these passages, rarely occurs, except as 
the result of mechanical injury, as from the lodgment of a 
foreign body, or from swallowing some caustic or highly 
irritating substance. Catarrhal or croupous inflammation of 
the mouth and tonsils, may, however, involve a portion of 
the walls of the pharynx. 

Ulceration may result from the same causes, and hence 
may be confined to a small portion or may involve the 
greater part of the tube. 

Stricture of the oesophagus may be either spasmodic or 
organic. The former usually occurs in hysterical women, 
and may result from the irritation following the removal of 
some foreign body lodged in the canal. Never proving fatal 
of itself, we seldom have the opportunity of examining a 
case of this kind. 

Organic stricture is found usually at the commencement 
of the canal, sometimes at its lower end. It may result from 
contractions attending; the healing of an ulcer, but is more 
frequently induced by a cancerous affection of the walls, or 



OF THE PERICARDIUM. 73 

by the projection of some morbid growth into its interior, 
as from aneurism of the aorta, or tumors, abscesses, &c, in 
the lunejs or left lobe of the liver. 

Dilatation of the oesophagus may result from the pres- 
ence of stricture. When the latter is near the cardiac orifice 
of the stomach, the entire length of the tube may be involved. 
The walls in these cases may be either thickened or thinned. 
From the accumulation of food above the point of stricture, 
the walls gradually yield to the distending force, until a de- 
gree of dilatation is attained that is quite remarkable. 

Tumors of various kinds are occasionally found within 
the walls of the pharynx or cesophagus t including cystic, 
fatty and fibrinous tumors of a polypoid form. 

Malignant or cancerous growths may appear in any part 
of the tube, the epithelial form being more common. Begin- 
ning in the submucous tissue, the disease will soon involve 
the whole circumference of the tube, to the extent of from 
one to three or four inches, producing a hardness of the tis- 
sues with more or less contraction. Ulceration ultimately 
taking place, a dilated cavity may take the place of the 
original stricture. 

Section IV. OF THE PERICARDIUM. 

[Notice: 1. External characters — shape; measurement ; amount of 
fat, etc. 2. Contents — serum; quantity; color; how affected by heat; 
blood; quantity; character; source. 3. Internal surface — adhesions; 
their position, extent and character; as firm, soft, etc.] 

The pericardium is subject to the same affections as other 
serous membranes, including inflammation, adhesions, effu- 
sions or morbid growths. 

Inflammation of the pericardium or pericarditis, is 
characterized by an unusual dryness of the surface, with 



74 PATHOLOGICAL CONDITIONS. 

injection of the vessels in the early stage, while at a later 
period a layer of plastic lymph will be found adhering to the 
surfaces. The deposit may be limited to some small portion, 
or be distributed over the whole inner surface of the mem- 
brane and upon the exterior of the heart, giving them the 
appearance of having been smeared over with some sticky 
substance. Often the surfaces are rough or villous in ap- 
pearance, like the mucous membranes of the intestines. 
Irregular calcareous patches are sometimes found in old 
chronic cases, developed within the thickened portions of the 
membrane. 

Adhesions may also form between the surfaces in con- 
tact. The whole cavity may in this manner become oblit- 
erated, or bands of adhesion may be found here and there. 

Kffusions may be found in the pericardium, as in other 
serous cavities. When the result of pericarditis, the fluid 
will often contain floating shreds of lymph. Sometimes the 
fluid will be found highly albuminous, and again bloody or 
mixed with pus. This effusion may have taken place so 
early as to have prevented any adhesion of parts ; or it may 
not have commenced until union had taken place at certain 
parts, when, from the distension of the sac, these bands may 
be found greatly elongated, and stretching across the cavity 
in various directions. When the effusion is but part of a 
general dropsy, it will be clear, while the surfaces of the 
membrane will be smooth and destitute of evidences of in- 
flammation. In quantity, the fluid found in these cases may 
vary from a few ounces to a pint or more. 

Blood may sometimes be found filling the pericardium, 
either from a wound of its walls, rupture of the heart, or 
from the bursting of an aneurism. In scurvy, purpura, etc., 
small patches of extravasated blood may be found in its 
walls. 



OF THE HEART. 75 

Morbid Growths. The more common of these, found 
in connection with the pericardium, are cancers. They are 
usually secondary in their appearance, and generally will 
have first developed in the mediastinum. 

Fibrous or cystic tumors have been noticed in a few rare 
cases, while tubercles of the miliary form, are not uncommon 
within this membrane. 

Section V. OF THE HEART. 



B 



[Notice : 1. In situ — exact position and relation to surroundin 
organs ; shape ; size ; degree of firmness or flabbiness. 2. After remo- 
val — amount and kind of blood discharged from divided vessels ; shape 
of heart; round or elongated; apex formed by which ventricle; amount 
of fat on surface ; relative size of each cavity. 3. Right auricle — char- 
acter and quantity of blood contained; fibrinous clot. Lining mem- 
brane; general condition of ; foramen ovale ; open or closed; thickness, 
consistence, etc., of muscular walls. Auriculo-ventricular opening; its 
shape; estimate of size by introducing fingers; rough or smooth; fibrous 
or calcareous deposits ; circumference. 4. Bight ventricle — nature and 
quantity of contents; fluid blood; blood clot; fibrinous clot; size; 
attachments of same to muscular columns ; firm or soft ; size of cavity ; 
thickness and condition of muscular walls; color, firmness, etc. 5. Tri- 
cuspid valves — natural, thickened, thinned or contracted ; granulations ; 
patches of calcareous matter ; degree of flexibility ; can they close the 
opening? Condition of chordae tendinese; length, thickness, flexibility, 
rupture, etc. 6. Pulmonary opening — size and shape; smooth or 
rough. Semilunar valves; thin and smooth, or thick, rough and inflexi- 
ble ; power of closing the opening; will water pass through when 
poured in from above ? 7. Left side of heart — observe same as on right. 
8. Generalities — weight after removal of blood ; wounds ; morbid 
growths ; abscesses ; malformations ; aneurism ; rupture, etc.] 



The several morbid conditions of the heart may be 
classified as follows : 

f of muscular walls. ( Carditis. 

1. Inflammations r v \ Pericarditis. 

| of serous membranes. | Endocarditis . 

f Thickening. 

2. Diseases of valves. -! Ossification. 



(^ Atrophy. 



4. Morbid conditions of the walls alone. 



76 PATHOLOGICAL CONDITIONS. 

3. Changes in the walls of the heart, in- C Hypertrophy, 
fluencing the size of the cavities. ■< Dilatation. 

(_ Atrophy. 

' Fatty degeneration. 
Morbid growths. 
Ossification of coronary 

arteries. 
Malformations. 
Abscess. 
Aneurism. 
Eupture. 

f p ., -I f Ectopia cordis. 

5. Displacements. j 1 Transposition. 

(Pathological. 

6. Contents of cavities. Heart clots. 



1. Inflammatory Affections. 

Carditis. Inflammation of the muscular substance of 
the heart is by no means a common disease, and when 
present, is probably always associated either with endocar- 
ditis? or more frequently pericarditis. We may recognize 
this condition after death, by the light yellow color of the 
heart ; with a relaxed, flabby, and in some instances a soft- 
ened condition of the walls. Upon cutting into the muscular 
walls, there will be found exuding a semi-purulent fluid, and 
often small cavities, varying in size from a pin's head to a 
small pea, will be found filled with pus. This condition 
may involve the whole heart, or may be confined to one or 
more portions. Inflammation of the muscular substance of 
the heart, may, undoubtedly, be one of the primary causes 
leading to aneurism or even to rupture. The symptoms of 
this disease are not readily recognized during life, being 
always combined with inflammation of the peri- or endo- 
cardium. 

Pericarditis. Affections of the pericardium have been 
noticed in the previous section. 



OF THE HEART. 77 

Endocarditis. Inflammation of the lining membrane 
of the heart {endocardium) most frequently occurs in con- 
nection with an attack of articular rheumatism. It may, 
however, result from blows or injuries of the chest, and has 
been induced by violent muscular efforts. It is said also, to 
be often connected with some vitiated condition of the blood, 
as in pyaemia or Bright's disease of the kidneys, and has been 
noticed also in cases of measles, typhus and puerperal fever. 

Endocarditis more frequently attacks the left, than the 
right side of the heart. The anatomical appearances, are a 
loss of smoothness and transparency of the membrane, with 
an injected condition of its vessels. Deposits of lymph may 
be found adhering to the free surface at various points, or to 
the tendinous cords or valves, giving a roughened, or even 
warty appearance to all those parts. These may become 
detached, and swept on with the blood, and finally lodging 
in some of the arteries of the head or extremities, where they 
are known as emboli, they may become a source of serious 
trouble. The inflammation may extend to the muscular 
structure, resulting in softening or the formation of puru- 
lent cysts. 

It is, however, upon those folds of the lining membrane 
constituting the valves, and particularly upon the left side 
of the heart, that the effects of endocardial inflammations 
are especially manifested. In this way originates most of 
the so-called 



2. Valvular Affections of the Heart. 

One of the most common of the results of inflammation 
extending to the valves, is 

Thickening. This may depend either upon a deposit 
of lymph beneath or between the layers of membrane con- 
stituting the valves, thus rendering them thick and inflex- 



78 PATHOLOGICAL CONDITIONS. 

ible while the surface is left smooth, or, at the same time, a 
deposit upon the exterior may be found, rendering them 
rough and even warty in appearance, and so stiffened and 
irregular upon their borders as to greatly interfere with the 
performance of their functions, and thus permitting regur- 
gitation to take place at the imperfectly closed opening.* 
The tendinous cords, at the same time, may be found 
thickened, hardened, and contracted, or even ruptured, 
while the auriculo-ventricular openings may also be found 
greatly contracted from the thickening of the base of the 
valves and the fibrous tissues forming the borders of the 
openings. Tn one case the contraction on the left side of the 
heart was so great as scarcely to admit the little finger, while 
the thumb should readily pass that opening. 

The semilunar valves of the aorta are liable to the same 
changes, their thickened condition preventing their folding 
back completely into the sinuses of the artery during the 
systolic action of the heart, or of completely closing the 
vessel upon pressure from above. 

Calcification. This condition of the valves may result 
from a progressive change from simple thickening with 
fibrinous deposits, to a cartilaginous state, accompanied 
with so-called bony, or more properly calcareous patches, 
which may involve large portions of the valves. Ossifica- 
tion of the valves upon the right side of the heart, is but 
rarely found ; upon the left, both the mitral and aortic 
valves are liable to this affection. 

Atrophy. The aortic, pulmonary, and sometimes mitral 
valves, are occasionally found greatly thinned; and this 
condition may result either in a gradual stretching of the 
central portion of the valve from pressure of the blood, 



* See No. 1385, College Museum. 



OF THE HEART. 79 

giving rise to aneurism of the valves, or, it may become per- 
forated with small irregular openings, or, from its weakened 
condition, rupture may take place, producing sudden death. 
This condition appears to consist in a gradual wearing away 
of the substance of the valves, from unusual brittleness of 
their structure, the result probably of chronic inflammation. 

Again, the valves may be found greatly contracted, 
(stenosis) hard and rigid, which will be attended with 
imperfect closure and consequent regurgitation. Dila- 
tation of the orifices without any change in the valves, may 
also be found, resulting in the same imperfect closure. 

Disease of the valves of the heart, by obstructing the 
orifices, is likely to result in 

3. Changes Affecting the Size of the Cavities. 

Hypertrophy. Hypertrophy of the heart, is a condi- 
tion in which there is an increased thickness of its walls, 
and generally also enlargement of its cavities. Yet there 
may be thickening — very rarely however — with a diminution 
in the size of the cavities. It may affect both sides of the 
heart, but is frequently confined to the left ventricle. 

The main cause of hypertrophy of the heart, is the 
existence of some obstruction to the circulation, either in 
the heart, or some portion of the arterial system, as by 
aneurism, pressure of tumors, etc., or by disease of the 
kidneys. It is most frequently, however, associated with 
disease of the valves or large arteries. It may sometimes 
result from continued functional excitement, and generally 
accompanies cases of partial adhesion of the surfaces of 
the pericardium, while complete adhesion is more likely 
to be followed by dilatation or atrophy. On the right side 
of the heart, hypertrophy is usually the result of some 
obstruction to the circulation through the lungs, as in an 
emphysematous condition of that organ. 



80 PATHOLOGICAL CONDITIONS. 

The following measurements, <&c, of the normal heart, 
will serve as a guide in judging of cases of enlargement : 

Size. Leennec has stated, that the heart in its normal 
condition, is about the size of the closed fist of the individ- 
ual. This comparison, however, is not very satisfactory. 
It will be usually found to measure about 5 inches in 
length, 3i in its greatest width, and 2i in its extreme 
thickness, from 'its anterior to its posterior surface. 

Weight. From an examination of four hundred cases, the 
average weight was found to be 9 2 ounces in the male, and 
8i ounces in the female. In a robust, muscular male, the 
heart may, however, be found to weigh as much as 12 
ounces, and still be normal in all its parts. 

Thickness of Walls. Right auricle, 1 line; left, li 
lines. Right ventricle, I2 lines, and left, a little over 5 
lines, or half an inch, at its middle, being a little thinner 
both at the base and apex. 

Size of Orifices. Circumference of auriculo-ventricular 
opening of the right side, nearly 4 inches ; of left side, 
Si inches; of the pulmonary artery, 2f inches; of aorta, 
21 inches. 

When enlarged, the heart may be found measuring 
6 to 7 inches in length, as much in breadth, and 12 to 16 
inches in circumference. The weight may also be increased 
to 15, 20 or 25 ounces, and the walls may increase in 
thickness to nearly a-half inch, and upon the left to over 
an inch. 

Hypertrophy of the heart, has been divided into three 
forms: — 1st, simple hypertrophy; 2d, eccentric; and 3d, 
concentric hypertrophy. 

In the first form, the walls are thickened, wdiile the cavi- 
ties remain unchanged. (Simple hypertrophy.) 

In the second form, the thickening of the walls is attended 



OF THE HEART. 81 

with an enlargement or dilatation of the cavities. (Eccen- 
tric hypertrophy.*) 

In the third form, the thickening is attended with a 
diminution in the capacity of the cavities. (Concentric 
hypertrophy.) 

It has been observed in cases where an examination has 
been made very soon after a sudden, violent death, attended 
with loss of blood, as in decapitation, etc., that the cavities 
have been nearly obliterated, while the walls were greatly 
thickened. By maceration for a few days, the ventricles 
have become relaxed to their natural size and capacity. 
This state of the heart has been observed in persons in 
whom, during life, none of the symptoms of disease of the 
heart had been manifested, and hence the condition is to be 
considered as the immediate effect of the peculiar character- 
of the cause of death. 

Dilatation. Dilatation of the cavities of the heart, is- 
a condition which may also result from the presence of 
obstacles or impediments to the circulation, as from ossifi- 
cation of the valves ; narrowing of the pulmonary or aortic 
orifices ; employments requiring powerful muscular efforts ;: 
and in consolidation, tubercular induration, emphysematous 
condition of the lungs, or fatty degeneration. 

The muscular substance is usually soft and flaccid, some- 
times of a violet color, again pale and yellowish. The thin- 
ning may be so great, as to reduce the thickest part of the: 
left ventricle to two lines or even less, when the walls will, 
appear to be composed of but little more than a thin layer 
of fat covered with the pericardium. 

Three forms of dilatation are recognized : active, simple 
and passive. 

Active dilatation is associated with hypertrophy of walls,, 
constituting eccentric hypertrophy. 

* See No. 1387 College Museum. 
6 



82 PATHOLOGICAL CONDITIONS. 

In simple hypertrophy, the walls retain their normal 
thickness, while the shape may be changed according to 
the cavity affected. 

Passive dilatation, on the other hand, is accompanied with 
thinning of the walls, and usually results from fatty degen- 
eration, atrophy, or some other change in the muscular fibre. 

Atrophy. In this condition there is a uniform decrease 
in the size of the heart. Its cavities becomes small, and its 
walls thin. It usually attends diseases accompanied with 
•great impoverishment of the blood, as in cancer, diabetes, 
etc., or may result from obstruction of the coronary arteries 
from calcification, atheroma or thrombi. 

Paget mentions a case where the heart of a cancerous 
man, fifty years old, weighed only five ounces, four drachms ; 
and that of a diabetic woman, which weighed only five 
ounces, one drachm. It is usually accompanied with a gen- 
eral wasting of the tissues and organs of the body, and fre- 
quently will be found associated with fatty degeneration, 
which will now be noticed. 

4. Morbid Condition of the Walls Alone. 

Fatty Degeneration. Two forms of fatty diseases of 
the heart have been recognized. In the first, which should 
be known as "fatty groivth" to distinguish from "fatty 
degeneration, 11 there is an unusual quantity of adipose mat- 
ter in those parts of the heart where more or less is usually 
found, viz.: — Along the furrows through which the vessels 
run, and particularly about the base of the heart. The 
fatty masses may dip more or less into the substance of the 
walls, displacing the muscular fibres, although, the latter are 
generally normal in color and density, even when imbedded 
in masses of fat. This condition may be found in persons 
who are otherwise thin, as well as in the obese. 



OF THE HEART. 83 

But the more frequent form of fatty disease, is that known 
as fatty degeneration. In this, we find upon opening the 
heart, that it lias lost the reddish -brown color characteristic 
of the muscular fibre in its normal condition, and is pale, soft 
and flabby. The whole organ feels soft, doughy and inelas- 
tic, much like a heart beginning to decompose. If the wall 
of the left ventricle be partly cut through, the remainder is 
easily torn, and the surfaces have a granulated appearance. 

Upon the inner surface, beneath the endocardium, numer- 
ous small thickly set spots, or sometimes wavy lines, of a 
pale buff, or light yellow color, may be noticed. This 
appearance does not depend upon a deposit of fat among the 
muscular fibres, but rather upon a change in that tissue ; 
and an examination with the microscope, will show fatty 
defeneration of the fibre. 

This condition of the heart, may involve the whole organ, 
or may be confined to one or more portions. It is much 
less common in the auricles, than in the A^entricles, and 
more frequent in the left ventricle than in the right. It 
will be generally found more advanced in the upper portion 
of the septum of the ventricles, and in the large, fleshy 
columns of the left side; or it may be found in these columns 
alone, which accounts for the occasional rupture of the 
latter. 

Fatty Degeneration may be associated with, fatty growth, 
or with hypertrophy, or thinning and dilatation, and may 
be the cause of rupture. The general character of softness, 
paleness, and mottled color, should lead to suspicion of the 
existence of this -disease, when a microscopic examination 
being resorted to, the conclusion would be decisive. A 
small portion of fibre, examined with a power of 300 or 400 
diameters, will present, in fatty degeneration, instead of the 
striated appearance of the normal fibre, a granular appear- 
ance, with numerous minute oil globules scattered through 
the fibre. In the palest part of the heart, the disease will 



84 PATHOLOGICAL CONDITIONS. 

be generally most advanced ; but even here, the microscope 
will show some fibres in a healthy condition, while others 
around them are rendered completely granular. 

Exhausting diseases of various kinds, typhus and other 
severe fevers, phosphorus poisoning, etc., may result in this 
peculiar condition of the heart. 

5. Morbid Growths. 

Under this head may be placed tumors, cancers, melanosis, 
and hydatids. 

Tumors of various kinds are occasionally found in con- 
nection with the heart. Fibrous tumors of a small size may 
develop within the muscular walls, while syphilitic growths, 
cysts, and tubercular deposits may also, in rare cases, be 
discovered. 

Cancer. Cancer of the heart has been noticed in two 
forms — epithelial and medullary. A man, fifty-eight years 
old, had an epithelial cancer of the eye, which was removed. 
Two years after, the man died with a large cancerous tumor 
over the parotid gland. A post-mortem examination re- 
vealed a cancerous mass, about an inch and a-half in diam- 
eter, imbedded in the apex of the right ventricle and septum 
of the heart. A microscopic examination revealed its epi- 
thelial character.* 

Medullary cancer of the heart has been usually found 
associated with the same disease in the lungs and liver, and 
forms an investing mass which may involve the whole organ. 

Melanosis of the heart presents the same character as 
in other parts of the body, and is considered but a variety 
of the medullary cancer, pigmentary matter being added. 



Paget's Pathology, p. 586. 



OF THE HEART. 85 

It may be developed upon the surface, or may infiltrate the 
substance of the whole organ. 

Hydatids have been occasionally found in the heart, 
the most of which have probably been animal in their char- 
acter, (acephalocysts.) A female, forty years old, who had 
been suffering pain in the region of the heart for some 
months, suddenly died, after running rapidly up stairs. One 
ounce of fluid was found in the pericardium. A considerable 
tumor was found at the apex of the heart, which slightly 
fluctuated. This tumor was about three inches in diameter, 
globular in form, and encroached considerably upon the 
cavity of the right ventricle. When laid open, it was found 
to contain a large number of small cysts or hydatids, vary- 
ing in size from that of a small pea to that of a pigeon's egg, 
the space between which was filled with a soft curdlike sub- 
stance, of a yellow color.* 

Ossification of Coronary Arteries. That condition 
of the arteries of the heart usually termed ossification is more 
properly one of calcification, consisting of a deposit of hard, 
gritty, calcareous matter, in which there is none of the true 
character of real bone, no trace of bone-corpuscle or vascular 
canals ever being discovered in them. Chemical analysis 
has shown the deposits to be composed of 50 parts of animal 
matter, with 47 £ of the phosphate and 2 of the carbonate of 
lime in every 100. This matter being deposited in circular 
layers, the artery becomes gradually converted into a hard, 
bony-like tube, which may be traced with the finger along 
the grooves of the heart through which the coronary artery 
runs. This is peculiarly a disease of old people, and may 
accompany a similar condition of the arch of the aorta or of 
the semilunar valves, and by interfering with the proper 

* Medico-Chirurgical Trans, xvii. p. 507. 



86 PATHOLOGICAL CONDITIONS. 

nutrition of the heart may result in other forms of disease, 
as fatty degeneration, dilatation, &c. 

Abscess. Abscess of the heart, may unquestionably 
follow an attack of carditis, or inflammation of the muscular 
substance. The cut surface of the heart in these cases, not 
unfrequently shows small cavities containing a purulent fluid, 
and in some instances a distinct abscess is found. 

A man, sixty years old, was suddenly, attacked, while at 
work, with coma and great feebleness, followed by death on 
the third day. The left ventricle being opened, an abscess 
was discovered near the apex, irregular in form, and con- 
taining a bloody, purulent-looking fluid. The coronary 
arteries were much ossified. 

Malformations of the heart, are extremely rare in adults, 
or even in children that have passed the early days of in- 
fancy. They consist frequently in arrest of development of 
the auricular septum, or, in other words, of a patulous foramen 
ovale, which, by permitting of a mixture of arterial and 
venous blood upon the left side of the heart, results in early 
death. I have in several instances found this foramen im- 
perfectly closed in the adult heart, but the opening has been 
so small— barely sufficient to permit the passage of a probe 
— as to offer little or no obstacle to the proper performance 
to the heart's function. Malformation of the heart is un- 
doubtedly one of the many causes of death in utero, which 
might be demonstrated by a post-mortem examination. 

Aneurism. Partial aneurism, or false aneurism of the 
heart, consists in the formation of a sac or pouch, in some 
portion of the walls of the organ, communicating with the 
cavity of the chamber, in the walls of which it has been 
formed. They may form in any part of the muscular walls 
of the heart, but are more frequent in the left ventricle. 



OF THE HEART. 87 

They would seem to result from a separation of some of the 
muscular fibres, when, try their retraction, a cavity or pouch, 
of a rounded or oval form results, which, in some instances, 
lias its walls composed of the pericardium alone, there 
being a complete destruction of the muscular fibres. 

The interior of these pouches, may be found filled with 
layers of coagulated fibrinous deposits, as in the case of 
aneurism of arteries ; or, if they, communicate with the 
ventricular cavity by a large opening, they may be filled 
with a simple soft clot of blood. 

The size of these aneurismal pouches, vary from that of a 
cherry, to a pigeon's egg, or larger, when they change much 
the usual figure of the heart, by their projection upon the 
external surface. 

The following conditions have been supposed to favor the 
formation of these aneurismal sacs : — 1st, softening of the 
muscular tissue of the heart ; 2d, ulceration of the lining 
membrane ; and 3d, rupture of the muscular fibres. 

Rupture of the walls of the heart sometimes happens, 
producing sudden death. It may result from severe contu- 
sions of the chest, in which case, the auricles are more likely 
to give way. More frequently, rupture will result from soft- 
ening of the walls in fatty degeneration or ulceration, or 
from the bursting of an aneurism of the heart, or from 
stenosis of the aorta. In the latter cases, the left ventricle 
will be usually the seat of the rupture. 



6. Displacements. 

Changes of Position of the heart, are by no means unfre- 
quent. They may be congenital in their origin, or the result 
of disease in the surrounding organs. Of congenital diS- 
placement, we may mention first : 



88 PATHOLOGICAL CONDITIONS. 

Ectopia Cordis, where, from some arrest of development, 
in the inclosing parts, the heart may be found in some 
position other than its normal one. From deficiency of 
the sternum and. ribs, the heart has been found protruding 
from the chest, [ectopia pectoralis,) or from absence or 
deficiency of the diaphragm, it may be found in the 
abdomen with the abdominal viscera. Such cases live but 
a short time after birth. 

Transpositio7i of the heart is found in those cases where 
all the viscera, abdominal and thoracic, are exactly reversed 
in position. A case of this kind was discovered in the dissect- 
ing room a few years ago, by Dr. R. B. Weaver, demonstrator 
of anatomy, in -the Hahnemann Medical College. The heart 
was here upon the right side, the aorta curving to the left ; 
the liver upon the left; the stomach with its pylorus to the 
left ; the colon commencing in the left iliac fossa ; in short, 
everything completely reversed in position. The subject 
was a female of about thirty years, and undoubtedly suffered 
no inconvenience from the abnormal positions. 

The more frequent displacements of the heart, however, 
are those resulting from disease in the surrounding struc- 
tures. It may be crowded from its normal position, by 
pleuritic effusions, accumulations of air (pneumothorax), or 
even by a highly emphysematous lung. Displacements may 
also result from the presence of aneurismal or other tumors 
in the chest; curvatures of the spine; or from a hernial 
protrusion of some of the abdominal viscera through an 
opening in the diaphragm ; or the presence of tumors, en- 
larged viscera, dropsies, etc., within the abdomen. 

7. Contents of the Cavities. 

Heart Clots. This subject is one that has until re- 
cently, been but imperfectly understood ; and now even, our 
knowledge relating to it, is by no means complete. Enough 



OF THE HEART. 89 

is known, however, to convince us that heart clots, are a 
more frequent cause of sudden death, than has been hereto- 
fore supposed. 

Having in a recent paper, read before the Philadelphia 
County Homoeopathic Medical Society, quite fully treated 
of this subject, I shall here merely transcribe the leading 
points of the same.* 

Fibrinous heart clots , polypus of the heart, or fatty depos- 
its, as they are sometimes called, differ from ordinary clots 
of blood, in the absence of the blood corpuscles, and hence, 
presenting the buff color characteristic of the coagulated 
fibrin of the blood. Ordinary blood clots, with the corpus- 
cles entangled with the fibrin — and hence presenting the red 
color of blood — are usually found in the cavities of the heart 
and large blood-vessels after death, but' in greater quantity 
upon the right side. 

Color. The shade of color presented by the fibrinous clot 
varies in different cases. While buffis the prevailing color, 
the shade varies from a light drab to a decided yellow. 

Consistency. In this respect a good deal of variation is 
also found ; the difference depending, probably, in part upon 
the character of the disease, and in part upon the rapidity 
or slowness of the formation; those of a rapid or very recent 
formation, having a soft, fatty, or jelly-like character ;•(* 
while, on the other hand, those of a more gradual formation, 
and with more sthenic forms of disease, acquire a considera- 
ble degree of density, the surface presenting a smooth 
appearance, as if acted upon by a current of blood, and in all 
respects resembling the dense fibrinous masses, found block- 
ing up the cavities of aneurismal tumors. 

Position. In every case reported below, the clot has 
been on the right side of the heart, although in some, a 

* See Hahnemannian Monthly for May, 1871. 

f In one case, the clot .presented a marked resemblance to the abdom- 
inal fat of the goose, both in color and consistency. 



90 PATHOLOGICAL CONDITIONS. 

small, soft clot has been found on the left. I am not sure 
that I have ever found one of these clots on the left side of 
the heart of such a size and consistency, or under such cir- 
cumstances, as to have led me to suppose that it might have 
been a cause of death. 

The body of the clot is usually found in the ventricle, 
extending from this, either up into the pulmonary artery, or 
through the opening into the auricle. In all cases, the clot 
has been more or less entangled with the tendinous cords of 
the valves and muscular columns of the heart, requiring, in 
some instances, considerable force to tear it away from its 
attachments. 

Time of formation. An important question to be decided 
in regard to these heart clots, is the time of their formation. 
Are they ante or postmortem in their origin ? And upon 
the solution of this query depends the conclusion as to 
whether they are the cause or the result of death in the 
cases where found. That a fibrinous clot may sometimes be 
formed in the coagulation of the blood outside of the body, 
is a fact well known ; as in the blood drawn from patients 
suffering from acute inflammatory affections, where, from 
the retarding of the coagulation, the blood corpuscles, from 
their greater specific gravity, have time to fall towards the 
bottom of the vessel, thus giving the " buffy coat" to the 
upper portion of the clot. The same cause — retarded coagu- 
lation — unquestionably may give rise to a clot in the heart 
after death, presenting the same character, viz., with the 
upper portion, of the buff, fibrinous character, while the 
lower portion, from the presence of corpuscles, will present 
the appearance of an ordinary blood clot. Such clots are 
not unfrequently found after death. 

But have we any evidence that the fibrin of the blood 
may be deposited, forming clots within the vessels during 
life ? In proof of this, we have only to refer to the result 
of the application of a ligature to an artery ; where the 



OF THE HEART. 91 

interval between the point of application and the first 
1 coming off above, will be filled with a fibrinous clot, 
which performs an important part in the closing up of 
the vessel ; or, to the well-known deposits of fibrinous 
layers within aneurismal tumors, sufficient, in many cases, 
to so fill up the sac as to result in a cure ; therefore, the 
favoring conditions being present, it is not unreasonable to 
claim that fibrinous clots may form within the heart, of such 
size and in such positions as to be an immediate cause of 
death. 

Causes. In looking for the causes, or conditions pro- 
moting the formation of these fibrinous deposits, we have 
to consider, first, variations in the character of the blood 
itself; and secondly, peculiarities in its circulation and in 
the circulatory apparatus. Fibrin, one of the normal con- 
stituents of the blood, is estimated by physiologists as 
forming from 2 to 3 parts in 1000, Avhile it may fall as low 
as 1, or rise to 7i parts. We find it reduced to the mini- 
mum quantity in all diseases which present a hemorrhagic 
tendency, as in true typhus, yellow fever, certain malignant 
forms of disease, and as the effect of many poisons, both 
animal and vegetable. In these cases, the loss of fibrin 
results in the effusion of blood into the tissues, producing 
petechial spots, or upon the mucous surfaces, giving rise to 
epistaxis, black vomit, hsematuria, etc., while very feeble, if 
any, coagulation of the blood will be found after death. 

In scurvy, however, where we have a condition of the 
blood not unlike that above referred to, there appears to be 
a marked tendency to the formation of clots, as has been 
noticed by many observers, and as has been verified by Dr. 
J. C. Morgan, in several cases which came under his notice 
wmile in the army. 

But it is in cases where there is at least a relative increase 
of fibrin, that heart clots are more liable to form. Such a 
condition we find in cases where, while the fibrin remains 



92 PATHOLOGICAL CONDITIONS. 

normal in quantity, the water of the blood, the menstruum 
in which the fibrin is held in solution, is below the normal 
standard, this reduction favoring the tendency to deposit. 
Thus, in all cases where there has been an exhausting and 
rapid flux from the bowels, as in cholera, or excessive 
purging from drastic cathartics, or from the colliquative 
sweating of phthisis, we have the favoring condition, and 
death may be the immediate result of a fibrinous clot in the 
heart. 

The most favorable condition, however, for the formation 
of heart clots, is undoubtedly that in which there is an abso- 
lute increase of fibrin, and this we find in a large number of 
diseases marked by 'acute inflammatory symptoms ; as in 
pleurisy, pneumonia, diphtheria, croup, acute rheumatism, 
erysipelas, puerperal fever, etc. In a large number of 
deaths from these diseases, a post-mortem examination 
would undoubtedly bring to light a heart clot, which has at 
least served to hasten, if it has not been the immediate 
cause of the fatal termination. 

Again, the formation of heart clots is evidently promoted 
by any circumstances or conditions, resulting in great feeble- 
ness or languor of the circulation, independent of variations 
in the amount of fibrin. A complete stasis of the blood is 
certain to be followed by coagulation ; as in employment of 
pressure in the treatment of aneurism ; so in cases of great 
prostration of the powers of life, attended with extreme 
feebleness of the circulation, as 1st. In cases of shock, 
where life is not immediately destroyed ; 2d. In certain 
cases of poisoning, as by opium, where the action of the 
heart is greatly depressed ; and 3d. In syncope, either with 
or without loss of blood. In all of these cases the danger 
of the formation of the heart clot is very great, and proba- 
bly in a large number this is the immediate cause of death. 

It is a fact well established, that loss of blood, either by 
haemorrhages or venesection, is followed by an increased 



OF THE HEART. 93 

coagulability of that fluid ; hence, the fearful haemorrhages 
which sometimes attend parturition, if accompanied with 
syncope, are in great danger of being followed by the forma- 
tion of the heart clot, and thus ending in death.* 

Another circumstance tending to promote the formation 
of fibrinous clots in the heart, is evidently to be found in 
the peculiar formation of the valves guarding the auriculo- 
ventricular openings. It is well known how fibrin may be 
collected from fresh blood, by beating the same with a 
bundle of twigs, the latter soon becoming coated with shreds 
of fibrin ; so the chordce tendinece and fleshy columns of the 
heart, between which the blood is continually being driven, 
affords convenient points for collecting the same from the 
feebly circulating or overcharged blood ; and from the close 
intermingling of the tendinous cords, with the substance of 
the clot, it is probably upon these that the deposit first 
begins to form. 

In explanation of the fact that fibrinous clots are almost 
universally found on the right or venous side of the heart, 
notwithstanding that arterial blood is richer in fibrin than 
venous, the following has been suggested to my mind: 
First. While venous blood contains a smaller proportion of 
fibrin, may not its deoxydized condition favor the more ready 
deposit of this substance, than by the more highly vitalized 
arterial blood ? Second. The feebler muscular power of the 
right side of the heart would necessarily be attended with a 
slower circulation through its cavities, the partial stasis of 
the blood giving another condition favorable for the forma- 
tion of a clot ; and Third. The valves of the right side of 
the heart, present three flaps or folds, instead of two as on 
the left, and hence, with their numerous tendinous cords, 
offer an increased number of obstructing points, around 
which the deposit may be made. These several circum- 

* Meigs' Treatise on Obstetrics, p. 308. 



94 PATHOLOGICAL CONDITIONS. 

stances would seem sufficient to account for the admitted 
fact. 

Symptoms. The symptoms attending the formation of 
fibrinous clots in the heart, are usually sudden in their acces- 
sion, frequently attended with a chill, and marked by great 
oppression in breathing, coldness of surface, and pallor of 
face and lips, the latter symptom distinguishing from the 
dyspnoea attending croup, asthma, pneumonia, etc., where the 
face is livid from venous congestion. The pulse is usually 
rapid and feeble ; the action of the heart labored, palpita- 
ting, and sometimes intermitting;, while auscultation will 
reveal a tumultuous churning-like action, the normal sounds 
being quite undistinguishable. 

Pulsation of the jugulars will be present in most cases, 
and where the clot greatly obstructs the play of the tricuspid 
valves, a double pulsation will be likely to be noticed. In 
the last stage, a copious cold perspiration appears upon the 
whole surface of the body. 

As might be -anticipated, fibrinous formations, while of 
small size, are sometimes washed away from their attach- 
ments and swept on with the current of blood into the 
arteries and carried to distant parts of the body, as is some- 
times the case also in aneurism, thus producing the embolic 
masses often found blocking up arteries in different parts of 
the body. When upon the right side, the embolus would 
be carried into the pulmonary artery, obstructing the circu- 
lation through the lungs, and producing symptoms more or 
less grave, according to the size of the clot. Upon the left 
side of the heart, from the greater force of the circulation, 
these bodies are probably more frequently swept away from 
their attachments and carried into the aorta, and thus on, 
perhaps, through the carotids to the head, or into the sub- 
clavian, or down the aorta, finally lodging in some of the 
branches of the lower extremities. Convulsions, paralysis, 
etc., are not unfrequently produced by the lodgment of 



OF THE HEART. 95 

emboli in some of the arteries of the brain, while, when 
carried into the arteries ol' the extremities, pain, falling of 
temperature, impairment of sensation, contraction of mus- 
cles, atrophy, and even gangrene may result. 

The following examples will serve to illustrate the class 
of cases to which I refer : 

Case I. — Death from Heart Clot in Ancemia. 

A lad, 11 year? old, and very anaemic, went to school in the morning 
in his usual health ; while there was taken with a chill. On his way 
home vomited freely. The chill lasted for a long time, and was ac- 
companied with an oppression in breathing, which gradually increased 
through the day and night, and until the time of my first visit at 
11 o'clock A. M. the next day. I then found him extremely pallid, 
lips bloodless, perspiring freely, suffering from great restlessness and 
distress, with extreme dyspnoea ; mind wandering, pulse irregular and 
feeble ; action of the heart very tumultuous, the normal sounds being 
unrecognizable. In the neck noticed a rapid rolling pulsation of the 
jugulars, which presented two beats to one of the artery at the wrist. 

At my second visit, made at 4 o'clock P. M., the patient had 
just expired. 

The autopsy, made twenty hours after death, gave the following 
results : Upon opening the abdomen found the liver presenting a dark 
mottled appearance, and highly congested ; other abdominal organs 
natural ; pericardium contained about one ounce of serum. Upon 
opening the right auricle of the heart, found a firm- fibrinous mass, ex- 
tending downwards through the ventricular opening, and which, upon 
the latter cavity being opened, was found firmly attached to the tri- 
cuspid valves, and entangled with the fleshy columns and tendinous 
cords. 

The presence of such a body in this position, and witlj such attach- 
ments, it was evident, must have so interfered with the passage of the 
blood from the auricle to the ventricle, as, upon the contraction of the 
former cavity, to have caused a backward pressure into the veins, and 
thus have produced the first of the double pulsations of the jugulars. 

Again, the position of this clot, preventing the closure of the valves 
upon the contraction of the ventricle, there would have been a regurgi- 
tation into the auricle, and the same backward flow into the veins, 
thus producing the second pulsation of the jugulars seen during life. 



96 PATHOLOGICAL CONDITIONS. 

Case II. — Death from Heart Clot in Pregnancy. 

A lady, 28 or 30 years old, also very anaemic, and three months 
pregnant, had been suffering occasional fainting spells. For some days 
before her decease she had suffered from dyspnoea, and on that day, 
after ascending a flight of stairs, fell upon the floor, and before a 
physician could be obtained breathed her last. A post mortem showed 
all the thoracic and abdominal viscera in a healthy condition, while 
the right side of the heart contained a large fibrinous clot, with attach- 
ments similar to those found in Case I. 

Case III. — Death from Heart Clot in Diphtheria. 

A boy, 3 years old, had an attack of diphtheria. The case presented 
no unfavorable symptoms until about the fourth day, when he was 
taken with great restlessness and oppression in breathing, and while 
sitting on the chamber at stool, suddenly died. The autopsy here 
again revealed the heart clot, as in the other cases. 

Case IV. — Death from Heart Clot in Consumption. 

A man, 30 years of age, a furrier by trade, was suffering from 
tubercular disease of the lungs. He had never given up his work, 
though he was much reduced in flesh, had a bad cough, diarrhoea, and 
night sweats. While at his employment, he was one day taken with 
great oppression, increased cough, etc., and in twenty-four hours expired. 

The post mortem showed that, while the upper portion of both lungs 
contained large deposits of tubercles, there were no abscesses, and the 
lower portions presented sufficient sound lung tissue to have maintained 
life. Upon opening the heart the usual fibrinous clot was found in 
the right ventricle, extending upwards into the auricle. 

Case V. — Death from Heart Clot in Rheumatism. 

A strong colored man, of 25 years, had an attack of inflammatory 
rheumatism. The disease presented the usual characters, the inflam- 
mation wandering from joint to joint. During the second week he 
was suddenly attacked with great difficulty in breathing, violent and 
irregular action of the heart, and great distress, followed by rapid 
prostration and death. The post-mortem examination revealed thick- 
ened tricuspid valves, with a firm clot of large size adhering to the 
same. 

Case VI. — Death from Heart Clot in Debility. 

A gentleman, 55 years old, who had been for some time in feeble 
health, was taken, upon rising in the morning, with oppression and 



OF THE HEART. 97 

distress in the region of the heart, dying in twelve hours. The heart 
clot was found here, as in the other cases, upon the right side of the 
heart. 

Case VII. — Heart Clot in Death from Over-dose of Morphia. 
A gentleman, of about 50 years, a physician, was found one morning 
dead in his bed. His health had been previously good, excepting that 
he was troubled with neuralgia which gave him sleepless nights, and 
for which he sometimes took morphia. On the night previous to his 
death he came home and retired at a late hour. An open bottle of 
morphia and small spatula were found on his desk next morning, the 
spatula showing evidence of having been thrust deeply into the mor- 
phia, and probably a large and over-dose carelessly removed and 
taken. The autopsy here again revealed a large and firm fibrinous 
heart clot. 

Case VIII. — Death from Heart Clot in Acute Gastritis. 

A lady of about 60 years, had an attack of acute gastritis, but was 
considered convalescing, and her physician (Dr. Martin) made his last 
visit in the evening. The next morning she was found dead in her 
bed. The post-mortem showed the spleen somewhat enlarged, and its 
capsule greatly thickened.* Other organs healthy, while the heart- 
contained an unusually large fibrinous clot, which has been preserved, 
in the College Museum. f 

The above include the more marked cases of death that have come- 
under my notice, where that result could, in my mind, be fairly attri- 
buted to the formation of fibrinous clots in the heart. 

The following inferences may, we think, be fairly deduced 
from the several cases reported : 

First. In some instances the fibrinous clots are apparently- 
the sole cause of death. (Cases 1, 2, and 3.) 

Second. In other, and a larger number of diseases, as in' 
acute rheumatism, pneumonia, croup, etc., which otherwise 
would recover, a fatal termination results from the formation 
of heart clots. (Cases 3 and 5.) 

Third. In still other diseases, which are of themselves- 
necessarily fatal, as in phthisis, cholera, etc., death is often 
hastened by these formations. (Case 4.) 

* No. 1470 College Museum. f No. 1344 College Museum. 



98 PATHOLOGICAL CONDITIONS. 

Section VI. THE AORTA AND ARTERIES GENER- 
ALLY. 

[Notice: 1. Before Opening Vessel — size; course; condition of ex- 
ternal coat and surrounding tissues. 2. After Opening Vesssel — char- 
acter of blood within ; coagulated or not ; size, color, consistence, etc., 
•of clot ; size of canal ; thickness of walls ; rigid or flexible. Lining 
Membrane — smoothness; transparency, etc.; readiness of detachment; 
.thickness, etc. ; if rough, the apparent cause ; fibrinous, atheromatous 
-or calcareous deposits. Middle Coat — its thickness ; color ; deposits 
within, and their character. External Coat — general condition. 

Aneurisms: — 1. External Characters — size; shape; is the dilatation 
ilateral or general in its relation to the vessel ? Openings as seen exter- 
nally; size, position, etc.; blood effused; quantity, etc. After opening, 
notice — contents; blood fluid or coagulated ; fibrinous contents; lami- 
nations; their thickness ; number; density; dryness; difference between 
outer and inner layers. Channel for blood: size; character of inner 
surface; how formed? Walls of aneurism: how formed ; by all, or one 
coat of artery. Size of artery above and below aneurism.] 

The diseases of the aorta, and of arteries generally, which 
may claim attention in a post-mortem examination, are 
inflammation, fatty degeneration, calcification, aneurism, 
•and rupture. 

Inflammation. This process may be found involving 
•either the outer or inner coats of arteries. In the former 
case the walls appear thickened and infiltrated with a soft, 
jelly-like substance, which appears, at a more advanced 
stage in some cases, to degenerate into a purulent condition, 
"while in others, great thickening of the coats, or even oblit- 
eration results. Inflammation of the inner coat generally 
precedes atheromatous or calcareous deposits, and is mostly 
confined to old persons. The roughened inner surface thus 
produced, may serve to collect fibrinous shreds from the blood, 
and thus be the occasion of the formation of emboli. 

Inflammation of arteries may result from injuries, from 
the presence of emboli, or may be spontaneous in its origin. 
While the more frequent seat of the disease is in the aorta, 
it may occur in any other artery. 



OF ARTERIES. 99 

Fatty Degeneration, or atheromatous disease of ar- 
teries, is an important affection of those vessels, and is usually 
:iated with aneurism. It is seen more frequently in the 
arch of the aorta, and consists in the presence of fine white 
streaks, situated in the substance of the lining membrane. 
The disease may be found in children as young as from three 
to seven years of age, but is more common with adults. 
As the disease advances, the middle coat becomes involved. 
The streaks gradually change into large, white, opaque 
patches. The middle coat becomes thinned, loses its elas- 
ticity, assumes a gray, semi-transparent appearance, and, at 
a later stage, becomes soft and cheesy, and sometimes even 
undergoes a form of liquification into a creamy fluid resem- 
bling pus, but dependent upon the abundant formation of 
fat globules, with scales of cholesterine and granular matter. 

While these destructive changes are going on in the inner 
and middle coats, and tending to their rupture, by a con- 
servative process, the outer coat, upon which the strength 
of the vessel mainly depends, becomes thickened and 
strengthened by the accumulation of plastic matter. 

Ossification. Ossification of the aorta, like that of the 
coronary and other arteries, consists rather in a process of 
calcification. The deposits are largely confined to the arch, 
and consist mainly of patches of calcareous matter of various 
sizes. We seldom find the whole circumference of the vessel 
involved, as in the case of smaller arteries. The aortic 
valves will generally be found more or less loaded with the 
same deposits.* 

Aneurism. This disease is said to occur more frequently 
in the aorta, than in any other artery. It may be devel- 
oped in any portion of this vessel or its principal branches, 



* Xo. 1385 College Museum. 



100 PATHOLOGICAL CONDITIONS. 

but is more commonly found in the arch. The walls of the 
vessel being weakened by fatty degeneration, they become 
less and less able to resist the pressure of the contained 
blood, and gradually yielding to the systolic force of the 
heart, become more and more distended, until the complete 
aueurismal sac is formed. 

Aneurism may be either true, in which there is a 
dilatation of all the coats of the vessel, or false, where there 
is rupture of the inner, and perhaps also of the middle, and 
dilatation of the outer coat alone. The latter form, when 
developed upon the aorta, may become very large, and by 
pressure, cause absorption of the sternum, costal cartilages 
and ribs, and even of the clavicle. 

In some cases, the inner and middle coat having ruptured, 
the blood instead of being confined in a sac formed by the 
outer coat, becomes diffused between the middle and outer, 
or between the layers of the middle coat, thus constituting 
what is known as dissecting aneurism. In these cases, the 
blood may extend the whole length of the aorta, and even 
upwards upon the carotids to their bifurcation. 

In an examination of an aneurismal sac, the true aneu- 
rism will be recognized by the walls presenting all the coats 
of the artery, and generally by the indication of the presence 
of atheromatous and calcareous deposits, which are confined 
to the inner and middle coats. In these cases also, the 
communication between the sac and the aorta is large and 
free. If the aneurism he false, however, there will be an 
absence of those deposits, the opening into the artery will 
be comparatively small, and the inner and middle coats will 
terminate abruptly at its margin. 

The interior of aneurismal sacs will usually be found con- 
taining a quantity of fibrin e deposited from the blood, and 
arranged in concentric layers. In color, these fibrinous 
layers are. of a light buff, the outer layers being dry and 
firm, while the inner ones are softer and more moist, and the 



OF ARTERIES. 101 

central portion, at the same time, filled with a dark mass of 
coagulated blood. A spontaneous cure will sometimes be 
effected by a complete blocking up of the sac with fibrinous 
deposits, thus preventing further dilatation or danger of 
rupture. 

The following case, which has been before reported,* 
shows a combination of both true and false aneurism, with 
spontaneous cure of the latter : 

Case. — Spontaneous cure of aneurism of ascending portion of arch of 
aorta, with death from bursting of aneurism of descending portion 
into the oesophagus. 

Mr. H , of this city, aged sixty years, while walking in his 

yard one day after a hearty dinner, was taken with a sudden sensation 
of faintness and nausea, which was soon followed by vomiting the con- 
tents of his stomach, with a considerable quantity of blood. After 
entering his house, the vomiting was frequently repeated, and at each 
e*ffort large quantities of pale blood ejected. Sinking rapidly, in an 
hour he was dead. 

Twenty-four hours after, I made a post-mortem examination. Upon 
exposing the chest, found at the right border of the sternum, just below 
the clavicle, a hard, inelastic tumor beneath the skin, of the size of a 
small orange. While not adherent to the integument, it appeared 
firmly attached to the walls of the chest beneath. Upon turning aside 
the integument and pectoral muscles, the tumor was found connected 
by a long pedicle to parts within the chest ; absorption of considerable 
portions of the sternal ends of the first and second ribs, with the side 
of the sternum, having resulted from pressure of the tumor upon those 
parts, and finally permitting its appearance beneath the skin. 

The removal of the sternum at once demonstrated the aneurismal 
character of the tumor by showing its connection with the ascending 
portion of the arch of the aorta, while a section of the same, exhibited 
the interior filled with dense concentric layers of fibrinous matter, 
separable from one another, the outer layers being dry and hard, 
while the inner portion was less firm and moist. This aneurism was 
plainly of the false variety. The neck of the tumor was not much 

* See article on Spontaneous Cure of Aneurism, with cases in New 
York Transactions of Homoepathic Medical Society for 18G8, page 170. 



102 PATHOLOGICAL CONDITIONS. 

larger than the thumb, and of sufficient length to reach from the arch 
of the aorta to the dilated sac beneath the skin, outside the chest. 

A further examination of the aorta brought to light a second and 
true aneurism of the descending portion of the arch, the dilatation in- 
volving all the coats of the vessels, and which, having burst into the 
cesopltagus, explained at once the cause of the haemorrhage and sudden 
death. 

Upon inquiring of the family, I learned that the tumor upon the 
chest had been known to have existed for fifteen or twenty years; that 
for some years the pulsations of the tumor were strong, but that for 
many years all beating had ceased; that he had never discontinued his 
work, that of a carpenter, and in fact, it had given him so little trouble 
that he had never consulted a physician in regard to it. For a year or 
so previous to death, he had been troubled with a cough, particularly 
upon exercising, but otherwise had been in good health. 

A remarkable and interesting feature of this case was, the little incon- 
venience experienced by the patient from so grave a malady, and one 
usually attended with great suffering. 

Rupture. Spontaneous rupture of the aorta is a very 
rare occurrence, and probably never happens except the 
coats have first been weakened by disease. Hence, in all 
of these cases, there will be found atheromatous softening, 
and generally thinning of the walls by dilatation. In this 
condition, some violent muscular effort may result in rupture 
at the most weakened point, and this will be generally at 
that portion of the aorta within the pericardium, the external 
coat being weaker here than at any other point. 

Where the dilatation of the diseased and weakened vessel 
has resulted in the formation of an aneurism, rupture of this 
will be the more frequent termination. This may take place 
into the oesophagus, as in the case reported, or into the 
trachea, the pericardium, either pleural cavity, or upon the 
surface of the body. 

Rupture of the coronary arteries, of the arteries of the 
brain, various branches of the abdominal aorta, and arteries 
of the extremities, have occasionally been found, when 
softened by fatty degeneration or atheromatous disease. 



OF THE PLEURA. 103 



Section VH. THE PLEURA. 

[Notice: Condition of membrane — inflamed; extent and position 
of; thickened; transparent or opaque ; rough or smooth. Contents — 
blood, gas, serum, pus. amount and probable source of. Adhesions — 
general or local ; firmness of, etc.] 

Like other serous membranes, the pleura is liable to in- 
flammation, both acute and chronic, with their results — 
plastic, serous, or purulent effusions, adhesions, etc. 

Inflammation. The first change which is observed in 
inflammation of the pleura (pleurisy) is a loss of the shining, 
transparent appearance of that membrane, it becoming dull 
and opaque. Red injected vessels, in minute ramifications, 
sometimes radiating from single points, in others more uni- 
formly diffused, will be noticed. Often the surface will 
present a red mottled appearance, with here and there 
small points of extravasation. This condition having ex- 
isted for from six to twenty-four hours, certain results follow 
— at least in the acute form — which give rise to what is 
known as 

Plastic Kffusion. Soon after the inflammatory process 
is fully established, there will appear upon the surface a 
small quantity of clear fluid, which, as it increases in quan- 
tity, undergoes coagulation, and thus gradually covers the 
surface with a jelly-like layer of variable thickness and 
honey-comb surface. A thin fluid of a straw color, will be 
found oozing from the surface, which is increased as the 
coagulated membrane is cut or torn. This condition may 
be extended over the whole surface of both the costal and 
pulmonary pleura, or may be confined to a limited portion. 

Adhesions. The two layers of the pleura being in im- 
mediate contact, the consequence of this effusion of coagulated 



104 PATHOLOGICAL CONDITIONS. 

lymph will be an early adhesion of the applied surfaces. 
This is accomplished by a blending of the layers of coagulated 
matter in contact, and a gradual organization of the same by 
an extension of blood-vessels from the pleura into the new 
formation. At the same time that these changes are pro- 
gressing, the watery part of the exudation trickles down to 
the most dependent portion of the cavity, and there forms a 
serous or sero-purulent accumulation. Adhesions are more 
frequent at the upper portion of the lungs, but may be found 
at any point, as between the inner surface and the medias- 
tinum, or the lower surface and diaphragm; or, from re- 
peated attacks of pleuritis, involving different portions of the 
serous membrane, the whole of the exterior of the lung may 
become united to the adjoining surfaces. 

The strength of the adhesions will be somewhat in pro- 
portion to their age, those of long standing requiring consid- 
erable force to break them up, and in many instances the 
lung tissues becoming lacerated before the attachments can 
be torn away. 

Unusual thickness of the pleura is often found at points 
where no adhesions exist, this being unquestionably the 
result of the effusion of plastic matter into the sub-serous 
tissue during an attack of inflammation. 

Serous Effusion, While in the majority of cases of 
pleuritic inflammation, we shall find plastic effusions fol- 
lowed by adhesions of the inflamed with the adjoining surface, 
in some instances a serous or watery fluid is rapidly poured 
out, and, accumulating in the pleural sac, constitutes hydro- 
thorax or dropsy of the chest. The fluid in these cases may 
present a variety of shades of color, from a pinkish or light 
straw color, to a dark brownish shade. It may be transparent 
or opaque, and generally will be more or less albuminous. 
The quantity may vary from a few ounces to three, four, or 
five pints, or more. "When in large quantity, the lung will 



OF THE PLEUEA. 105 

be found more or less collapsed, shrunken, and pressed against 
the posterior walls of the chest and spinal column. 

In the general dropsy attending diseases of the heart, 
kidneys or liver, effusions may take place into the pleural 
cavities, to such an extent as to give rise to great dyspnoea 
from compression of the lungs. 

Sero-Purulent or Puriform Effusions, consist in the 
presence of a quantity of granular particles with albuminous 
matter, which subside to the bottom of the vessel when 
drawn off, and always contains floating flakes of lymph. It 
may be found in cases of both acute and chronic pleurisy, 
and, like serous effusions, may be found in large quantity. 

Purulent Fluid, as found in the cavity of the chest, 
consists of a white or cream-colored, opaque, and homogeneous 
fluid, combined with more or less albuminous matter, in the 
form of shreds and flakes, yet destitute of the granular matter 
of the sero-purulent fluids, and not separating into a fluid 
and solid portion when at rest, as is the case with the latter. 

It is a fact well established, that genuine purulent matter 
may be formed in the pleural cavity, as well as in other 
serous cavities, without ulceration of any portion of the sur- 
face, or discharge of an abscess into the same, it being the 
result of a more advanced stage of the process which gives 
rise to the serous or plastic effusions. It may be secreted 
directly from the capillaries of the inflamed surface, or, in 
some instances, it would appear to be derived from the 
organized false membranes, which have taken on a suppura- 
tive action. 

Pneumothorax. Air may enter the pleural cavity, 
by perforation of the walls of the chest from external injury, 
or, as is more common, by the destruction of the pulmonary 
portion of the membrane, from the bursting of a distended 



106 PATHOLOGICAL CONDITIONS. 

air-cell, or from softening of tubercular deposits, or bursting 
of an abscess. If there are but few or no adhesions, the 
accumulation of air in the cavity may be accompanied by a 
more or less complete collapse of the lung, as in hydrothorax. 
This condition, during life, is not readily distinguished from 
emphysema, both being accompanied with similar oppression 
in breathing, distension of the chest, and displacements of the 
heart, and with increased clearness on percussion. Serous 
or sero-purulent effusions will frequently accompany the 
presence of air in the cavity, and thus give rise to many of 
the peculiar physical signs which may have been noticed 
during life, as metallic tinkling, a splashing sound on shaking 
the chest, etc. 



Section VXH. THE LUNGS AND BRONCHIAL TUBES. 

[Notice: 1. While in situ — degree of collapse ; adhesions; position 
and character of ; wounds, etc. 2. After removal — external character; 
color ; peculiarity of shape ; adhesion of lobes ; puckerings at apex ; 
solid or compressible ; crepitation ; where most noticeable ; effect of 
inflation on color and size. Tubercular deposits — size; location. 3. 
Substance of lung — solid or porous when cut ; extent of solidified por- 
tions; fluids escaping; character and quantity of. Abscesses — position; 
number; size; character of contents; color; odor, etc.; condition of 
lung around cavities ; character of walls ; thick or thin ; smooth or 
rough ; crossed by bands ; communication with bronchial tubes. 
Gangrene— location and extent of. Bronchial tubes — contents; con- 
traction or dilatation ; measurements at, above and below these points ; 
condition of mucous membrane; congested or ulcerated; walls of tubes ; 
thicker or thinner than natural. Extravasation of blood — (apoplexy of 
lung ;) portion and extent of lung involved ; condition of surrounding 
tissue; blood infiltrated or encysted. Adventitious deposits — cretaceous 
bodies; situation; size; density; condition of surrounding tissues. 
Tubercles — seat; size; number; color; density, etc.; condition of sur- 
rounding tissue. Cancerous masses — size; location, etc. Carbonaceous 
deposits — around bronchial tubes : beneath pleura. JRcsidt of placing 
entire lungs in water — do they sink or float ? If they sink, is it rap- 
idly or slowly? If they float, is it above, below, or at the surface of 
the water ? Results with portions of each lung.] 

The pathological conditions of the lungs, may be arranged 
as follows : — Inflammation and its results, hepatization, 



OF THE LUNGS. 107 

suppuration, abscess, gangrene, hozmmorrliage, pulmonary 
apoplexy, emphysema, tubercular disease, morbid growths, 
and 'parasitical animals. 

When in a healthy condition, the lungs will present the 
following appearance: — Upon opening the chest, there will 
be a more or less complete collapse of both organs, partly 
from atmospheric pressure, and partly from the elasticity of 
the lung tissue. They will then have a shrunken, shrivelled 
appearance, crepitating under pressure, and have an ashen 
gray color. If inflated, the surface becomes smooth and 
shining, showing an indistinct outline of the lobules, which, 
with the dark pigmentary matter seen here and there, gives 
the surface more or less of a mottled appearance. 

Where pleurisy had previously existed, there may be 
adhesions preventing the collapse of the lungs, until these 
have been broken up. When cut into, healthy lung tissue 
has a soft, spongy character, the upper portions will be quite 
destitute of blood, while the posterior portions may be more 
or less filled with that fluid from gravitation, giving them a 
dark congested appearance. 



Inflammation and its Results. 

Pneumonia, or inflammation of the lungs, may affect 
both the air cells, when the latter become filled with 
fibrinous exudations, and the connective areolar tissue, 
which then become increased in quantity. 

The following characters present themselves, correspond- 
ing to the three recognized stages of the disease: — First, 
congestion; second, red hepatization; third, gray hepati- 
zation or softening. 



Congestion. From the peculiar structure of the 1 
in connection with the free circulation through the 



ungs, 



- same, 



108 PATHOLOGICAL CONDITIONS. 

these organs are peculiarly liable to the several forms of 
congestion. In many cases of death, without any original 
disease of the lungs, there will be a tendency for these 
organs to become loaded with blood, giving rise to post- 
mortem appearances, often with difficulty distinguished from 
those of a pathological origin. In this post-mortem, or, as it 
has been called hypostatic congestion, the posterior and 
inferior portions of the lungs are chiefly affected, as the 
blood after death, obeying the law of gravitation, sinks to 
the lowest point. The congested portion presents a dark 
red color, and though firmer than other portions, crepitates 
under the finger and floats in water, the latter circumstance 
serving to distinguish this form of congestion from that of an 
inflammatory origin. If the congestion be confined to one 
lung, or to the anterior parts of either, we may safely 
attribute it to a pathological cause. 

In all cases of congestion, upon opening the chest, although 
there may be no adhesions, the lung does not collapse, 
or does so feebly. When cut, it is found to be loaded with 
blood, and upon pressure, much bloody serum escapes, while 
the divided bronchial tubes will be found filled with frothy 
mucus. 

Red Hepatization. This condition of the lungs soon 
follows that of congestion. The change is a gradual one, 
and is first marked by an effusion of serum and coagulable 
lymph into the connective tissue and air-cells, thus render- 
ing the lungs more solid, while as the change becomes com- 
plete, the blood itself, which had during the congestive stage 
been confined to the vessels, is now found extravasated into 
the interstices of the tissues. The portion of the lung thus 
affected is not only of a dark red or violet color, but solid, 
firm, does not crepitate, sinks when thrown into water, and 
when cut and washed, the section shows patches of a rough, 
granular aspect, totally different from that of healthy lung 



OF THE LUNGS. 109 

tissue. The pleura in this condition may be wholly un- 
changed, even though the solidification may have been of 
long standino;. 

Gray Hepatization, which characterizes the third 
stage of pneumonia, is known by the lung presenting a firm, 
semi-solid, inelastic, and more or less incompressible char- 
acter. Failing to collapse, the lung is found more or less 
completely filling the chest. The pleura will generally pre- 
sent evidences of inflammation in the presence of patches of 
lymph and more or less points of adhesions. The upper lobe 
may be soft and compressible, Avhile the lower is solid from 
hepatization. When divided with the knife, the substance 
is found of a gray, red, or dirty yellow color ; compact, but 
friable and easily broken down with the fingers, while the 
smaller bronchial tubes are filled with fibrinous plugs. 
Bloody purulent matter, with much turbid serous fluid, will 
ooze from the cut surfaces. Pus globules will be detected 
in the escaping fluids by a microscopic examination. 

Piesolution of a hepatized lung, consists in the gradual 
softening of the effused substances within the smaller bron- 
chial tubes and air cells, and the discharge of the same by 
cough and expectoration. 

Inflammation of the lung usually commences in the lower 
lobe, and while the disease here may extend to complete 
hepatization, the middle lobe may be found merely con- 
gested, while the upper is quite healthy. Inflammation may 
attack one or both lungs. In the former case it is known 
as single, and in the latter as double pneumonia. From an 
examination of a large number of cases, it has been ascer- 
tained that inflammation of the right lung is more frequent 
than that of the left in the proportion of about three to one, 
and that single pneumonia is more common than double 
pneumonia in the ratio of six to one. 

Pneumonia is sometimes divided into Catarrhal and 



110 PATHOLOGICAL CONDITIONS. 

Croupous. In the former, the exudation contains little or 
no fibrinous matter, while the bronchial mucous membranes 
are also involved, the disease at the same time being con- 
fined mostly to the lobules of the lungs. In the croupous 
form, the exudation contains a large proportion of fibrine, 
and the disease usually involves the greater part of a lobe, 
or may extend to the whole of one or both lungs. 

Both forms of the disease may run through the three 
stages of congestion, red and gray hepatization. 

A peculiar form of inflammation of the lungs, found mostly 
in children and young persons, and usually chronic in char- 
acter, has been described as 

Lobular Pneumonia. The inflammation here being 
confined to the lobules, these, after the disease is perfectly 
developed, present the appearance of a multitude of rounded 
nodules, of the size of small nuts, scattered through the sub- 
stance of the lungs. The exterior of these is reddish, firm, 
and vascular, while the interior is of a grayish color, con- 
taining effused lymph, with more or less purulent matter. 

This form of pneumonia being frequently associated with 
diseases of the joints and bones, as well as with inflammation 
and ulceration of the glands of the intestines, it has been 
considered as depending upon a strumous diathesis, and as, 
in fact, but the early stage of tubercular consumption. Sel- 
dom proving fatal in the early stage, or before the disease 
has extended to the whole, substance of the lung, and perhaps 
resulted in the formation of cavities, we much less frequently 
meet with this form of pneumonia in post-mortem exam- 
inations. 

Suppuration and Abscess. Gray hepatization must 
be looked upon as a form of suppuration of the lungs ; as 
the purulent-looking fluid found infiltrating the tissues, filling 
the air-cells and smaller bronchial tubes, upon a microscopic 
examination, is found containing undoubted pus globules. 



OF THE LUNGS. Ill 

This, however, is not an abscess, the matter not being con- 
fined within a cavity, but diffused through the tissues of the 
part. That a distinct abscess of the kings may form, as a 
result of pneumonia, is generally admitted, though they are 
usually small and confined to the lower lobes. From soft- 
ening of tubercular masses, abscesses not unfrequently form 
in any portion of the lungs. That they do not occur more 
frequently in pneumonia, may result from the fact that the 
disease often proves fatal by suffocation, before there has 
been time for it to have reached the suppurative stage. 

The pleura over the seat of the abscess will generally be 
found much thickened, and frequently adherent to the oppo- 
site walls of the chest. Pulmonary abscess may be wholly 
discharged by expectoration — the cavity communicating 
with the bronchial tubes — or it may discharge into the 
pleural cavity, or when adhesions have first formed, it may 
wwk its way between the ribs, and the matter escape upon 
the surface of the body. 

Metastatic or Secondary Abscess. This form of 
abscess in the lungs, is well understood to be the result of 
suppuration in some distant part or organ, which, being- 
attended with phlebitis of the part, purulent matter is intro- 
duced into the circulation, and thus conveyed to the lungs 
or perhaps the liver. This original suppuration may be at 
the uterus after delivery, or from a fistulo in ano, psoas 
abscess, or any other similar affection. 

From the fact, probably, that the whole volume of the 
blood flow T s through, the lungs, at each round of the circula- 
tion, these organs are more frequently affected with this form 
of abscess than any other, it occurring next in frequency in 
the liver. These abscesses may be recognized as spots of 
yellow pus, varying in size from a pin's head to a walnut, 
generally situated near the surface of the organ and sur- 
rounded by a dark, well defined layer of congested tissue, 



112 PATHOLOGICAL CONDITIONS. 

while beyond this, the structure is in a healthy condition. 
Several of such abscesses may be found in various parts of 
the lungs. 

Gangrene. Gangrene of the lungs, rarely results from 
an attack of ordinary pneumonia, but appears more fre- 
quently to take place either as a concomitant of pestilential 
fevers in general, or as an accompaniment of certain cases of 
tubercular vomicae of the lungs, or as a primary and peculiar 
species of inflammatory affection of those organs. 

In the first instance, a patient suffering a severe form of 
typhoid fever, presents symptoms of pulmonary disorder, as 
hurried respiration, livid face, cough, first dry and soon 
moist, with thick orange-colored and finally dark or bloody 
and extremely offensive expectoration, and fetid breath. 
With these symptoms are generally associated great feeble- 
ness, delirium, with tendency to gangrene of the extremities 
and prominent points of the hips, sacrum, etc, ; and finally, 
with increased difficulty in respiration and fetor of breath, 
death ensues. 

In the second case, a patient suffering from clearly recog- 
nized tubercular disease of the lungs, which has passed on to 
softening of tubercular masses, and the formation of vomicae, 
has an aggravation of all his symptoms, accompanied with 
the expectoration of a highly offensive dark matter, plainly 
resulting from a gangrenous condition of the interior of a 
tubercular cavity. 

In the third case, the disease comes on at first as an 
affection of the lungs. The attack commences either as 
pulmonary inflammation, or bronchial disease, or with spitting 
of blood with more or less pain in the chest. The patient 
becomes rapidly worse, the cough increasing, with reddish 
brown or bloody sputa, and offensive breath. The counte- 
nance is anxious and livid, the eye heavy, sometimes 
wild and glaring. The fetid breath is not always an early 



OF THE LUNGS. 113 

symptom, but when it does appear, the disease in general 
tends rapidly to a fatal termination, although recovery 
sometimes takes place.* 

The appearances after death, in cases of gangrene of the 
lungs, are of two kinds, according as the disease is diffuse 
or circumscribed. 

11 In the first case, a mass of lung, two and a-half or three 
inches wide, but irregular in figure and outline, is converted 
into a soft, pulpy, dark, ash-colored substance, which, when it 
is handled or pressed by the fingers, falls down into a loose, 
moist mass, emitting a fetid, offensive odor, without trace of 
the usual structure of the lungs, except a few bronchial tubes, 
and blood-vessels, and shreds of filamentous tissue. This 
mass is generally bounded by, but it does not terminate 
abruptly in, healthy lung. It is soft, dingy, and infiltrated 
with a dark, ash-colored, dirty, serous liquor. Occasionally 
the surrounding portion of the lung is hepatized or infiltrated 
with blood or bloody serum ; the bronchial tubes always 
contain much bloody, viscid mucus ; and sometimes the 
pleura is reddened, covered with lymph or adhesions, and 
contains fluid in its cavity." 

The portion of the lung thus affected is usually within 
the lower or middle lobe, the upper portion being rarely in- 
volved. 

In the second, or circumscribed form, a portion of the lung, 
generally near the surface, presents a dark- colored, hard 
patch, varying in size from a quarter, to a half-dollar piece or 
more, often quite circular, and bounded all round by healthy 
lung. This circular hard patch, which resembles closely an 
eschar produced by caustic potash, may adhere or be easily 
detached. In the latter case, it generally leaves a cup-like 
cavity, the surface of which is firm, granular, with the blood- 



* See case of recovery reported by Dr. E. Koch, in American Jour 
of Horn. Mat. Med., Vol. IV., p. 123. 

8 



114 PATHOLOGICAL CONDITIONS. 

vessels and bronchial tubes closed, and with the surrounding; 
lung more softened, but generally presenting marks of pleu- 
risy, pneumonia, and bronchitis all combined, which may be 
looked upon as an effort of nature to isolate and detach the 
diseased mass. 

Pulmonary Haemorrhage — Haemoptysis. Discharge 
■of blood from the lungs by coughing, may result from a 
variety of causes, among which may be mentioned : 1, me- 
• chanical shock or injury, as in falls or blows upon the chest; 
:2, inflammatory action within the lungs ; 3, disease of the 
heart ; 4, disease of the arteries ; 5, tubercular deposition ; 
•6, tubercular destruction, with ulceration of vessels. 

In the first instance the expectorated blood may be copious 
or slight, according to the severity of the injury. If death 
soon results, an examination of the lungs will disclose one or 
more of the bronchial tubes filled with blood, which has 
plainly arisen from a rupture of some of the capillaries of the 
bronchial mucous membrane. The blood discharged in many 
cases of the early stage of consumption, and in young females 
after the suppression or retention of the menstrual flow, is 
from the same source. 

Haemorrhage from the lungs may also take place as a result 
of tubercular deposits. The presence of tubercular masses 
must necessarily produce more or less pressure on the adjoin- 
ing vessels, interfering with the flow of the blood through the 
same, and thus inducing congestion, and even rupture of 
some of the capillary branches. Again, where tubercular 
masses have progressed to softening, and a cavity has been 
formed, the ulcerative process may open a large vessel, and 
death result in a few minutes from excessive haemorrhage. 
A post-mortem will here show the cavity, as well as the 
bronchial tubes and trachea, filled with coagulated blood. 

The blood expectorated during the early stage of an attack 
of pneumonia, is never copious, consisting mainly of streaks 



OF THE LUNGS. 115 

of blood through the saliva, while at a later stage, from being 
more uniformly diffused, it gives the peculiar rusty sputa 
characteristic of this disease. The post-mortem appearances 
have already been given under the head of pneumonia. 

Certain forms of disease of the heart, as ossification of the 
mitral valves, with contraction of the orifice, or in hyper- 
trophy of the left ventricle, with disease of the aortic valves, 
are frequently attended with haemoptysis. In either case, 
the obstruction to the free circulation through the left side of 
the heart, must induce an over-distension of the pulmonary 
veins, which, upon some unusual exertion, may readily result 
in extravasation through the bronchial mucous membrane, 
causing the bloody expectoration which takes place during 
life, or into the pulmonary connective tissue, giving origin 
thus to what is known as 

Pulmonary Apoplexy. The post-mortem appearances 
in these cases, are as follows : — The portion of the lung 
involved, fails to collapse on opening the chest. It is firm, 
and of a dark red color ; and when cut into, thick blood 
issues from the cut surfaces. The portion involved may 
include from one to four cubic inches. It will be found 
circumscribed with healthy lung tissue, and looks not unlike 
a clot of venous blood ; these circumstances serving to dis- 
tinguish it from hepatization, which terminates more or less 
gradually in sound lung. 

While these hemorrhagic effusions may, in many cases, 
cause early death by their size and number, in others, the 
clot may soften, the lung around become inflamed, or even 
gangrenous, resulting in the formation of an irregular cavity 
filled with dark, offensive, semi-fluid contents. In still 
other cases, where the clot is small, and in part within the 
air-cells, it may soften and become absorbed or coughed up, 
and the air again enter the cells, or these may contract 
into a fibrous indurated mass. 



116 PATHOLOGICAL CONDITIONS. 

Emphysema. Emphysema of the lungs, is usually 
described as of two forms — vesicular and interlobular. 

Vesicular emphysema, consists essentially in a dilatation 
or over-distension of a greater or less number of air cells, 
resulting in giving the portion involved greater buoyancy in 
water, from diminished specific gravity, lessening the crepi- 
tation on pressure, preventing collapse on the opening of the 
chest, and rendering the affected portion more or less dry 
and bloodless. From the loss of elasticity, there will be 
during life, a difficulty in the lungs emptying themselves of 
air as they should, hence the patient will be subject to 
severe attacks of oppression upon the slightest aggravating 
cause. If one lung only is affected, the corresponding side 
becomes enlarged and less movable than the other ; the 
adjoining viscera, as the heart or abdominal organs, are 
more or less displaced, the intercostal spaces swell out, and 
the ribs becoming more horizontal, give a barrel-shape to 
the chest, which is quite characteristic of emphysema. 

This distension of the air-cells, is more marked along 
the edges of the lungs, the vesicles at these parts being 
probably the least supported. Patches of dilated cells may 
be found, however, at other parts, which, if superficial, will 
project beyond the surface of the surrounding healthy por- 
tions, and appear like large bladders, from the coalescing of 
several vesicles. 

This form of emphysema may be induced by any cause 
interfering with the ready escape of the air from any portion 
of the lungs, especially if accompanied with severe cough, as 
in many forms of bronchial disease, enlargement of the bron- 
chial glands, etc. 

Interlobular Jtimphysema, consists in an effusion of air into 
the connective or areolar tissue of the lungs, from a rupture 
of air-cells or smaller bronchial tubes, or from the laceration 
of the lungs from a broken rib, when the air may accu- 
mulate in the pleural cavity, constituting pneumothorax, 



OF THE LUNGS. 117 

and may also be accompanied with emphysema of the 
chest, neck and head, from an escape of the air at the point 
of injury into the tissues of those parts. This form of em- 
physema may involve a large part or the whole of the 
lung, while the vesicular form is generally limited to defi- 
nite portions. By disturbing the circulation through the 
lungs, emphysema is liable to induce dilatation of the right 
side of the heart. 

From an evolution of gases within the lungs after death, 
we may have similar appearances to that above described, 
requiring some care to distinguish between the two. In the 
latter case, the general indications of decomposition, with the 
ease with which these distended vesicles may be emptied by 
pressure, will aid in determining the character of the case. 

Tubercular Disease of the Lungs, 

I shall not attempt to present here the various theories 
that have been promulgated as to the nature and origin of 
tubercle, contenting myself by giving a description of their 
anatomical characters, as presented in the several stages of 
tubercular disease. 

Tubercle, or tubercular matter, may be described as con- 
sisting of a yellowish-white substance, opaque, friable and 
unorganized. It may be deposited in most of the tissues or 
organs of the body, but its more common seat is the free 
surfaces of mucous membranes, though often found in con- 
nection with the serous. 

Tubercular deposits in the lungs, are not uniformly dis- 
tributed through all parts of those organs, being in the large 
majority of cases confined to the upper and back part of the 
upper lobes, and in those cases where they are more or less 
distributed through the whole lung, they will be found more 
numerous and larger in those parts. 

Tubercles may exist as fine points, not larger than a pin's 



118 PATHOLOGICAL CONDITIONS. 

head, {miliary tubercle,) or the matter may accumulate in 
masses of the size of a kernel of corn, of a cherry, or of a 
robin's egg. In other cases, the pulmonic exudation in some 
portion of the lung attending an attack of pneumonia, may 
become transformed into tubercular matter, having an irreg- 
ular outline and no distinct boundary, (infiltrated tubercle) 

Tubercular matter is undoubtedly, in most instances, 
deposited within the. air-cells, so filling these, as to more or 
less interfere with the admission of the air, and giving greater 
density to the portion of lung involved. While the secreted 
matter is at first soft, or semi-fluid and partially translucent, 
it gradually acquires greater density, becomes opaque and 
cheesy in its character, and in all respects acting as a foreign 
body within the lungs. Sooner or later, the presence of 
tubercles will excite inflammation in the surrounding tissues. 
In this manner these bodies may become softened and their 
substance expectorated. If large numbers be aggregated 
together, the ulcerative process may completely destroy the 
tissues between, an abscess or vomica resulting. 

In the early stage of the disease, before the inflammatory 
and ulcerative processes have been set up, the presence of 
tubercular matter, by interfering with the capillary circula- 
tion, may give rise to a haemorrhage into the bronchial 
tubes, constituting the haemoptysis so frequently present in 
this disease ; while at a later period, from a destruction of 
some of the larger vessels from ulceration, a profuse and 
even fatal haemorrhage may result. 

Post-mortem Appearances. 

In examining the lungs of those who have died after 
suffering the usual symptoms of pulmonary consumption, we 
shall find the upper portion of one or both lungs, more or 
less indurated, and occupied by one or more irregular shaped 
cavities, containing either air, or air and a quantity of viscid, 



OF THE LUNGS. 119 

puriform, dirty-looking fluid. Generally the apex of the 
affected lung, will be found firmly attached to the inner 
surface of the chest, by means of a thick, firm, false mem- 
brane, which unites the two layers of the pleura. In some 
instances, nearly or quite the whole surface of the lung will 
be found thus adhered, while the lobes will also be united by 
an interlobular false membrane. When the adhesions are 
confined to the upper portions of the lungs, the pleura 
covering the lower portion will frequently be found more or 
less rough from albuminous exudation, while a quantity of 
sero-purulent fluid will be found in the posterior part of the 
thoracic cavity. 

The greater part of the upper lobe, may be found con- 
verted into one irregular cavity ; more frequently, the upper 
lobe presents two or three, either isolated or communicating. 
The largest, when several are present, is most commonly in 
the upper portion of the lobe. When entirely or partially 
filled with matter, such cavities are usually termed vomicce 
or abscesses, while when empty, they are generally called 
tubercular cavities or excavations. 

In the lower part of the upper lobes, the cavities are few 
and small. The middle lobe of the right lung, rarely pre- 
sents cavities, while the lower lobes of both lungs are entirely 
free. The whole of these parts, however, may be more or 
less indurated by the presence of hard, irregular shaped 
masses, the result, probably, of inflammatory action. 

Tubercular cavities present a considerable variety, both in 
size and shape. They may not be larger than a pea, or 
bean, or may reach the size of an egg, or even of an orange. 
Always of an irregular shape, they often consist of one large 
cavity, communicating with two or three smaller ones. The 
interior will be found traversed by bands, or cords, passing in 
various directions, but generally taking a longitudinal course, 
and probably the remnants of blood-vessels and bronchial 
tubes. 



120 PATHOLOGICAL CONDITIONS. 

The tissues immediately around a cavity, and forming its 
walls, will be found firm, inelastic, almost cartilaginous in 
character, and of a dark red, or brown color. The density of 
the structures is caused partly by tubercular deposits in 
the lung, and partly by inflammatory induration. 

While tubercular disease of the lungs is almost universally 
fatal, there is reason to believe that, in a very small propor- 
tion of cases recovery has taken place, and the post-mortem 
appearances of the lungs have accorded with this view. 
These appearances may be described as follows : 

We sometimes observe in examining the lungs of indi- 
viduals who may have died from diseases of other organs, 
that the pleura covering the upper lobe of the lung, presents, 
at a certain point, a puckered, shrivelled appearance, with a 
leather-like feel, and with a rounded, firm mass beneath. 
Upon dividing the latter with the knife, the interior is found 
composed either of a soft substance like putty, or more fre- 
quently of a chalky nature. This is looked upon as a cica- 
trized or contracted vomica, the putty or chalk-like contents 
being the residuary matter of the softened tubercle, the 
thinner portion having been expectorated or removed by 
absorption. In some instances, these bodies are of almost a 
stony hardness, grating against the knife. 

In other cases, cavities lined with a smooth, semi-carti- 
laginous false membrane are found, containing air only, and 
with dilated bronchial tubes opening into the same, no ap- 
pearance of ulceration being visible, everything indicating 
that a tubercular mass had once occupied the cavity, its soft- 
ening and expectoration having been followed by a healing 
of the inner surface. 



Morbid Growths. 

Cancer. Malignant disease of the lungs is by no means 
frequent, yet we have abundant evidence that cancer in its 



OF THE LUNGS. 121 

several forms may be developed in these organs. Colloid 
cancer, has been usually found more or less infiltrated through 
the substance of the lungs, while other forms appear in 
nodules or isolated tumors. 

It is seldom, perhaps, that cancer exhibits itself as a pri- 
mary affection of the lungs, the disease first appearing in 
some other part, and more frequently, it is said, in the bones 
or testicles ; operation for the removal of cancer in these 
parts being very liable to be followed by an early develop- 
ment of the disease in the lungs or other internal organs. 
On the other hand, where the cancer is connected with any 
organ whose veins form a part of the portal system, as the 
stomach, spleen, pancreas, intestines, etc., the disease does 
not so frequently extend to the lungs, while in those cases 
the liver is more liable to become affected. 

The encep haloid form of cancer, is that more frequently met. 
It may be connected either with the bronchial glands, when 
the diseased mass will be mainly confined to the mediastinum, 
and may consist of bodies varying in size from that of a 
cherry to that of a large apple, or, the disease may commence 
directly in the substance of the lungs, the tumor rapidly in- 
creasing in size, and crowding the lungs from their normal 
position. After death, the encephaloid mass may be found 
compressing the lungs into a very small space. The tumor 
presents the usual character of this disease, some of the 
lobules being soft and pulpy, or brain-like, others of a more 
firm, cheese-like consistence. 

Melanosis. Two forms of melanotic deposits are ob- 
served in the lungs : one, true melanosis, and frequently 
associated with encephaloid disease ; the other a deposit of 
carbonaceous matter from coal dust, smoke, etc., which has 
been inhaled during life, and distinguished as spurious mela- 
nosis. 

True melanosis consists in a deposit of a dark pigmentary 



122 PATHOLOGICAL CONDITIONS. 

matter in the substance of the bronchial glands, found at the 
bifurcation of the trachea, and along the main bronchi. The 
glands are at the same time enlarged. The coloring matter 
may be solid, or slightly fluid, or pasty. At the same time 
the melanotic matter may be infiltrated to some extent into 
the substance of the lungs, or deposited in cysts within the same. 
In s]Durious melanosis, the dark carbonaceous matter is 
diffused more or less through the whole lung, and may be 
seen distinctly through the pleura. The bronchial mucous 
membrane is more or less tinged with the same substance, 
and generally a quantity of black-colored fluid may be ex- 
pressed from the cut surfaces. 

Hydatids. Acephalocysts or animal hydatids, have not 
unfrequently been found in the lungs, and in several instances 
they have been discharged by expectoration. 

These cysts vary in size from a cherry to an egg, and 
consist of a double membrane containing a limpid fluid 
within which other hydatids may be found, of the same 
character as the parent cyst. They may excite inflammation 
and suppuration in the tissues around, and thus become 
discharged into the bronchial tubes, the pleural cavity, or 
through the diaphragm into the abdominal cavity. 

Cystic, Fibrous, Cartilaginous, and other forms of tumors, 
are occasionally found in the lungs, and, while they are 
generally small, they may acquire such size as to become a 
source of trouble during life. 

The Bronchial Tubes. 

The examination of the trachea and bronchial tubes in 
post-mortem examinations, is too frequently omitted. The 
lungs having been removed from the chest, they may be 
readily opened along their posterior aspect, and the bron- 
chial tubes traced into the substance of the lungs. The 



OF THE BRONCHIAL TUBES. 123 

pathological conditions of the bronchial tubes which may 
claim our attention, are inflammation in its various forms, 
obliteration, and dilatation. 

Bronchitis. Bronchial inflammation has been divided 
into two varieties, according to the portion of the tubes 
affected. In one case the disease may be confined to 
the large and medium sized tubes ; it is then known as 
tubular bronchitis. In the other, it is seated principally in 
the terminal ends, where the lining membrane is more deli- 
cate, and the tubes much smaller, and from this, extend- 
ing to the air cells, forms what has been called vesicular 
bronchitis. The latter form is closely allied to pneumonia ; 
in fact the two diseases pass into each other, and in most 
cases probably co-exist. 

Ordinary, or tubular bronchitis, is not often a fatal 
disease, hence we cannot speak accurately of its anatomical 
characters ; yet, being frequently associated with other forms 
of fatal disease, we have opportunities of examining it under 
those circumstances. The lining membrane is then found 
thickened, rough, of a dark red or brown color, with more 
or less contraction of the calibre of the tube, and covered 
with a viscid, jelly-like mucus, often streaked with blood, 
and in some cases of a puriform character. This form of 
bronchitis may occur as a primary disease, or it may accom- 
pany tubercular consumption ; is frequent in cases of heart 
disease, and may arise in the course of typhoid fever, measles, 
scarlet fever, and small-pox. 

Vesicular bronchitis, from its involving the smaller tubes 
and air cells, is much more frequently fatal than the tubular 
form of the disease, although in fatal cases the two forms 
will usually co-exist. In a post-mortem examination of these 
cases, we find the bronchial membrane red and injected, pulpy 
and thickened. In a more advanced stage, the air cells and 
smaller tubes are filled with a viscid, puriform mucus, which 
prevents the air from reaching the vesicles during life, and the 



124 PATHOLOGICAL CONDITIONS. 

lungs from collapsing upon opening the chest after death. 
Minute ulcers are not uncommon upon the mucous mem- 
brane, the effect of these, being that of changing the character 
of the secretion from a transparent mucoid, to an opaque 
purulent form. 

Bronchial inflammation, as has been stated in another 
place, may result in emphysema of the lungs. Tn these 
cases, a valvular-Jike obstruction is produced in some of the 
bronchial tubes, which, offering little impediment to the 
entrance of the air, interferes with its escape, and thus by 
producing increased pressure upon the air cells supplied by 
the obstructed tube, a gradual dilatation or rupture ensues, 
resulting in the former case in vesicular, and in the latter, 
in interlobular emphysema. 

Disease of the heart may also result from chronic bron- 
chial inflammation. Not only respiration, but the circula- 
tion may be so impeded as to exert a direct influence upon 
the heart. From the difficulty which the blood encounters 
in flowing through the branches of the pulmonary artery, the 
main trunk of that vessel becomes permanently dilated, 
while the right ventricle, from the increased force required 
to overcome the obstruction in the lungs, becomes gradually 
dilated, and at the same time, perhaps, hypertrophied. 
From the union of the two ventricles, the excessive action 
of the right may induce a similar action in the left, and thus 
in time result in that hypertrophy of both ventricles, which 
is sometimes found in persons who have suffered from 
chronic bronchitis. 

Narrowing or Obliteration of Bronchial Tubes. 

In some cases, in carefully tracing the bronchial tubes, we 
may find either a remarkable narrowness of the vessel, or a 
complete closure of the same. In the former cases, there is 
a distinct thickening of the walls of the tube, by an effusion 
of lymph, or blood and lymph, into the submucous tissues; 



OF THE BRONCHIAL TUBES. 125 

or, from induration of the lung tissue around the smaller 
bronchial tubes, from tubercular or other deposits, a similar 
narrowing may result from external pressure. 

Complete closure may be found in any portion of the 
tubes, in the large trunks, arising from the main branches, as 
well as in the smaller branches. They may be detected by 
passing a blunt probe into the tubes. The branches will fre- 
quently be found continuing from the points of closure, as a 
fibrous cord. The most common seat of these closures is 
in the upper lobe of the lung, yet they have been found 
in the lower lobes. 

The causes of obliteration of the bronchial tubes is not 
well understood, yet, they are more frequently observed in 
persons who have suffered repeated attacks of bronchitis, or 
of chronic pneumonia. 

Dilatation of the Bronchial Tubes. This condi- 
tion of the bronchial tubes is more frequent in its occurrence 
than obliteration. It takes place in two forms, either sev- 
eral tubes are uniformly dilated, like the fingers of a glove, 
or a single tube may form a cavity, by undergoing a sacular 
enlargement. Some mechanical obstruction, by interfering 
with the free passage of air through the tubes, will usually 
have caused the difficulty, as an enlarged bronchial gland, 
pressing one of the bronchi. Here the free exit of the 
respired atmosphere being prevented, an accumulation of air 
takes place behind the narrowed point. Any impediment 
to the entrance or exit of the air into the lungs will produce 
irregular and forcible breathing, and throw a greater strain 
upon those parts especially which are in the vicinity of the 
obstacle. If, at the same time, the patient suffers an attack 
of asthma, bronchial catarrh, or whooping-cough, the violence 
of the cough materially aids in developing the dilatation. 

The degree of dilatation is greatly variable. Tubes which, 
in their natural state, are not larger than a crow-quill, may, 



126 PATHOLOGICAL CONDITIONS. 

especially in the lower and middle lobes, reach the size of the 
finger, while at various points, sacular dilatations may occur, 
which at first sight may appear as vomicae, but which upon 
more careful inspection, prove to be dilated portions of the 
bronchial tubes. The tubes in this state are usually filled 
with a puriform fluid, upon the removal of which the lining 
membrane is seen to be reddened and softened, or perhaps 
ulcerated. 

This condition of the bronchial tubes may frequently be 
detected during life. The voice is hoarse, like a person in 
croup. The cough is also hoarse and brazen, while the 
breathing is difficult, and mucus rattling is heard in the 
middle or lower portion of the lung. 

The post-mortem appearances in cases of foreign bodies 
in the bronchial tubes, may be readily anticipated and easily 
recognized. 

The Mediastinum. 

Inflammation may arise in the anterior mediastinum, 
from fracture or caries of the sternum ; and in the posterior, 
from injury, inflammation, caries, or necrosis of the vertebrae. 
This inflammation may also result in the formation of an 

Abscess ; or, ulceration and perforation of the oesophagus, 
or inflammation of the lymphatic glands may lead to the 
same results. These abscesses may reach large size, result- 
ing in displacement of the heart, and may rupture into the 
pleural cavity, the trachea or oesophagus. 

Tumors of various kinds, may also develop within this 
space, including the several forms of cancerous growths. 
The latter will frequently have their origin in the bronchial 
or lymphatic glands, or, perhaps, in the remnant of the 
thymus gland. 



PART III 

THE ABDOMEN AND PELVIS. 



CHAPTER I. 
THE OPERATION. 

The cavity of the abdomen, may be opened without dis- 
turbing that of the chest. An incision from sternum to 
pubes, down the central line, and through the superficial 
structures, should be followed by a careful division of the 
tendinous portions of the muscles and peritoneum, for a 
sufficient space to admit two fingers, when, by introducing 
the same, the remaining portion maybe divided without risk 
of injury to the intestines. A cross incision having been 
made at the umbilicus, the angular flaps may be turned 
aside, fully exposing the abdominal contents. Where the 
chest is opened at the same time, the transverse incision 
will not be required. The peritoneum, with any serous or 
other contents having been examined, the attention may be 
given to any special organ or part that may be involved, or 
each may be taken up seriatim. 

In many instances there will be no occasion for removing 
any of the viscera, while in others, one or all of the organs 
may require so careful an examination, as to necessitate 
an entire removal from the body. 

The small intestines may be removed en masse, or in sec- 
(127) 



128 WHERE THE THORACIC VISCERA ARE EXAMINED. 

tions. After applying double ligatures at the lower end of 
the illeum, and just below the duodenum, the bowel may- 
be divided between these, when, by dividing the mesentery 
near its intestinal border, with either the knife or scissors, 
the whole mass may be removed. By means of the en- 
terotome, they may now be rapidly laid open through their 
entire length, the contents removed, and the surface cleansed 
if desired for more careful inspection. Occasionally, portions 
only of the small intestines will require examination. By 
applying double ligatures, above and below the portion to 
be examined, the removal is effected without escape of the 
contents into the abdominal cavity. 

In the removal of the colon, either in sections, or as a 
whole, the same care should be observed in the application 
of the ligatures. The rectum having been divided, it may 
be lifted and rendered tense, its attachments, with those of 
the ascending transverse and descending colon, being suc- 
cessively divided with the knife, and thus the whole gut 
removed and afterwards split open with the enterotome. 

The removal of the rectum, for the examination of its 
whole length, will usually require the removal of the other 
pelvic viscera, directions for which will be given further on. 

In all cases where the stomach is to be examined, it will 
be better first to remove it from the body. To accomplish 
this, both omenta should be detached from the curves of the 
stomach, which may be done either with the fingers or scis- 
sors. The hand may now be carried down to the cardiac 
end of the stomach and the fingers forced around the oesopha- 
gus without the use of the knife, and a ligature placed upon 
that tube. A ligature should also be placed just below the 
pyloric orifice, and another an inch below this. The knife 
or scissors may be used to divide the oesophagus close to 
the diaphragm, and the duodenum between the two ligatures ; 
the stomach may then be lifted from its position without loss 
of any of its contents. 






OPERATION ON THE ABDOMEN. 129 

If the object is merely to make a chemical analysis of 
the contents, the stomach should be placed immediately 
in the vessel prepared for its reception, and carefully 
sealed and labelled. If, on the other hand, we may wish to 
examine the inner surface of the organ, it may be freely 
opened along one of the curves with the scissors, the 
contents removed, and the mucous surface cleansed with a 
stream of water, for more satisfactory inspection. Both the 
contents and the stomach, may still be preserved for chemi- 
cal examination, should the circumstances of the case seem 
to require it. 

From the manner in which the duodenum is bound 
down to the posterior abdominal walls by the peritoneum, 
some little care will be required in its removal. Ligatures 
should be applied for retaining the contents, as directed with 
the stomach. 

The kidneys, with the suprarenal capsules, may be 
reached by lifting the intestines, and tearing open the 
peritoneum with the fingers. The gland may then be 
readily lifted from its position, and the vessels divided 
with the knife. To examine the interior, the gland may 
be split open longitudinally along its convex border, 
which will give a view of the cortical and pyramidal por- 
tions, with the interior of the sinus and pelvis. For 
microscopic examination, portions should be hardened in 
alcohol or solution of bichromite of potassa. 

The spleen may be easily removed from its position, by 
dragging it from its bed, in the left hypochondriac region, and 
dividing its vessels and omental attachments to the stomach. 

The pancreas may be brought into view, by tearing open. 
the great omentum just beneath the stomach, when the s 
gland may be seen behind the peritoneum, extending trans- 
versely across in front of the aorta. To remove it from its 
position will require some care, owing to its being bound 



130 OPERATION ON THE ABDOMEN. 

down to the posterior walls by the peritoneum, and closely 
attached to the duodenum by its right extremity or head. 

The liver may be generally examined in situ. The 
condition and contents of the gall bladder, the size, color, 
density, etc., of the gland, may all be noted without removal. 
Where, however, we may desire to ascertain the weight 
of the gland, or to examine its posterior and upper sur- 
face, its removal will be required. Where the chest has 
previously been opened, this will not be a difficult oper- 
ation . In other cases, the cartilages and ribs, form- 
ing the lower boundary of the chest, should be strongly 
►elevated by an assistant ; the operator then, by dragging 
,-down the liver, having first divided the suspensory ligament, 
.may expose the coronary and lateral ligaments, which will 
rrequire care in their division, to avoid opening through the 
diaphragm into the chest. The fingers should be now freely 
-tised, to peel the gland from the diaphragm. From the 
.•close connection of the liver to the ascending vena cava, this 
vessel will require to be divided at the upper border of the 
liver, close to the diaphragm, and again, after the gland has 
been rolled from its bed, at its lower border, with also the 
.portal vessels, hepatic artery and duct, which reach the 
transverse fissure through the border of the lesser omentum. 

The liver may now be lifted from the body, and placed 
in any convenient vessel for a more detailed inspection. 



The Pelvic Viscera. 

The whole pelvic viscera, with the external organs of 
^generation, in either the male or female, may be removed 
together, in the following manner : — Apply a double ligature 
.to the upper portion of the rectum, and divide the gut 
between. The. peritoneum may now be divided around the 
border of the pelvis, in the female, at the same time, cutting 



OPERATION ON THE PELVIS. 131 

across the round and broad ligaments of the uterus, when, 
with the hand, the bladder may be stripped' down from the 
inner side of the pubes, the rectum torn from the hollow of 
the sacrum, and in the same manner the parts torn off from 
the sides of the pelvis, using the knife only for dividing the 
more closely adhering points. 

Now, after flexing .the thighs upon the abdomen, an 
incision may be made through the skin of the mons 
veneris just over the anterior commissure of the vulva 
of the female, and over the penis of the male, and then 
carried back upon either side of the genital organs, 
meeting behind the anus, near the point of the coxcyx. 
This incision may be carried through the superficial tissues, 
down to the pubic arch, when the crura of the penis, or 
clitoris, may be detached from the rami of the pubes, by 
carrying the knife close to the bone. The finger may now — 
after a slight use of the knife — be pushed beneath the arch 
of the pubis, and made to appear in the pelvis. Taking 
this as a guide, the knife may be introduced at this 
opening, and carried deeply along the ramus of the ischium 
and pubis of either side, dividing the levator ani muscle 
and pelvic fascia. The bladder may now be drawn forward 
beneath the arch, this followed by the rectum, deep incisions 
being carried back to the tuberosities of the ischia and 
point of coxcyx, and thus the whole mass removed entire. 

The external parts may afterwards be so drawn together by 
stitches, as to make the absence of the external organs 
scarcely noticeable, while a bundle of rags crowded into the 
pelvis from above, will prevent the possible escape of any of 
the abdominal contents. 

Where the internal organs only, are required to be re- 
moved ; after they have been detached upon* all sides as 
before directed, the knife may be carried down beneath the 
pubic arch, and the urethra divided, in the male, just in ad- 
vance of the prostate. Incisions may now be carried back 



132 OPERATION ON THE PELVIS. 

upon either side of the bladder and rectum, dividing the 
levator ani muscle, when, by drawing upwards upon the 
mass, the rectum, and in the female, the rectum and vagina, 
may be divided near their lower ends, and the whole 
removed together. 

In many cases it may be desired to remove the uterus of 
the female alone. This may be done by dividing the broad 
and round ligaments upon either side, when, by dragging 
the uterus forcibly upwards, the vagina may be cut across 
about an inch below the cervix, and thus the organ removed. 
In all cases, a few rags should be crowded into the pelvis 
for the purpose of preventing the escape of any fluids. 

In hospital cases, where parts are to be exhibited to a 
class, and especially if several organs are involved in the dis- 
ease, the whole thoracic and abdominal viscera mayberemoved 
together and brought before the class on a large tray. This 
may be effected in the following manner: — A single incision 
may be carried from the upper end of the sternum to the 
pubes, and the sternum removed in the usual manner. The 
trachea and oesophagus, with the large vessels of the arch of 
the aorta, may now be divided at the root of the neck. 
Grasping the arch of the aorta and the trachea, the whole 
thoracic contents may be stripped from the spinal column. 
The diaphragm being now separated from its attachment to 
the ribs on either side and the spinal column, the whole ab- 
dominal contents may, in the same manner, be dragged from 
above downwards, the rectum tied and divided, and the con- 
tents of the two great cavities removed entire and with little 
disturbance of the relation of parts. 

In closing up the cavity after the examination is com- 
pleted, the viscera having been replaced, a sufficient quantity 
of wheaten bran or clean sawdust should be thrown in to 
absorb any remaining fluids, thus preventing their escape 
pfter the sewing up of the incisions. 






OF THE PERITONEUM. 133 

CHAPTER IT. 
PATHOLOGICAL CONDITIONS. 

Section I. OF THE PERITONEUM. 

[Notice in examination: — 1. Contents of cavity — serum; amount, 
color, coagulable or not ; pus — amount, consistence, odor, source ; 
blood — amount, source; foreign bodies; gall-stones; worms. 2. Con- 
dition of membrane — color, transparency, rough or smooth, moist or 
dry, thickness ; adhesions — position and strength of. Vascularity ; 
ulcers; perforations; tubercles; tumors; wounds, etc.] 

This membrane we find liable to congestion, inflammation, 
gangrene, effusions, and morbid growths. 

Congestion of the peritoneum, may result from obstruc- 
ted circulation through the liver, or ascending vena cava, 
or from inflammatory action; and may terminate in serous 
effusions into the abdominal cavity, or thickening of the 
membrane. The redness of congestion, may be distinguished 
from that of inflammation, by the larger vessels appearing 
more involved, and by the absence of any plastic effusions. 

Inflammation of this membrane, (Peritonitis,) may be 
either acute or chronic. 

Acute peritonitis, in most instances, commences at some 
one or more points, and from this gradually diffuses itself 
over the membrane until it becomes general. Such point of 
inflammation may commence immediately over some in- 
flamed, or ulcerated, or perforated spot in the intestines, or 
in the peritoneal covering of an inflamed uterus, liver, etc., 
or as the result of external injury. 

In the early stage of peritonitis, the injected vessels give 
the membrane a more or less red appearance, which will be 



134 PATHOLOGICAL CONDITIONS. 

more marked in streaks and patches. From the readiness, 
however, with which fibrinous exudation takes place from 
this membrane, this redness is seldom very strongly marked, 
and in some instances will scarcely be noticed, unless 
the surface is carefully scraped, thus removing the exudation. 

Small extravasations of blood are occasionally found in 
the substance of the membrane. The muscular coat of the 
intestines, where -the peritoneal covering is involved, may 
become infiltrated with serum, the fibres relaxed and para- 
lyzed, thus permitting of the great tympanitic distension 
found in these cases. 

Chronic peritonitis, is not a very common occurrence. 
It may, however, follow an attack of acute peritonitis, 
and is sometimes found in connection with ascites, or 
tubercular deposits in the peritoneum. In examining the 
body of a colored woman who had died of heart disease, 
accompanied w T ith general dropsy, and who had suffered 
abdominal pain and tenderness for a number of weeks 
previous to death, a large portion of the peritoneum, partic- 
ularly that reflected upon the abdominal walls, was found 
intensely red, the blood-vessels having an arborescent 
arrangement, and being beautifully injected. No plastic 
matter was found effused upon the surfaces. The cavity 
contained some twelve quarts of serum. 

Fibrinous Exudation, as already observed, readily 
follows inflammation of this membrane. It will often be 
found as a uniform layer covering the whole surface of the 
peritoneum, rendered more apparent, however, by separating 
parts, when it appears as delicate bands or filaments, stretch- 
ing across the interspace. In cases of acute inflammation, 
this plastic effusion is often very great, and frequently 
intermixed with purulent matter, while the serous fluid, 
which is poured out in considerable quantities in these cases, 
is rendered turbid by the presence of numerous flakes of 






OF THE PERITONEUM. 135 

fibrin, and quantities of pus cells diffused through the same. 
More or less extensive and firm adhesion of parts may thus, 
be induced, the plastic matter effused becoming more and 
more firm, and finally converted into dense bands of fibrous 
tissue. 

Mechanical obstruction and strangulation of the bowels, 
may be induced by the presence of these bands, stretching 
between parts, and forming thus an opening through which 
the bowel passes, and finally becomes incarcerated. 

Suppuration is not an unfrequent result of acute peri- 
tonitis ; the matter being found uniformly smeared over the 
whole surface, or, in some cases, confined to a single part, 
thus forming a circumscribed abscess. Adhesions having 
taken place around the boundaries of the suppurating sur- 
faces, in this manner the diffusion of the matter is prevented, 
and its discharge into the intestinal canal, or in some 
instances upon the surface of the body, is promoted. 

Gangrene of the peritoneum may result from intussus- 
ception or hernial incarceration of some portion of the bowel, 
when the part will appear as a softened, dark, offensive mass, 
limited by a band of highly congested tissue. 

Ascites. Dropsical accumulations in the abdominal 
cavity, may result from obstructed circulation, caused by 
disease of the liver, kidneys, heart or lungs ; or from pressure 
upon the vena cava, or portal vein, by some abnormal 
growth. 

The fluid effused may be nearly colorless, or present 
various shades of yellow, red or green, and usually coagu- 
lates on the application of heat. The peritoneum may 
appear unchanged, or it may present a thickened, opaque, 
white or macerated appearance, in chronic cases. 

Blood may be found in the peritoneal cavity, as a result 



136 PATHOLOGICAL CONDITIONS. 

of wounds, rupture of some of the abdominal or pelvic 
organs, or bursting of an aneurism. 



Morbid Growths. 

Tubercular Deposits, of the miliary form, are not un- 
frequent in the peritoneum. They may be diffused over the 
whole membran-e, as semi-transparent, gray granules, but 
more frequently are found on the under surface of the dia- 
phragm, in the neighborhood of the spleen, and on the viscera 
generally, while the parietal layer is more free. The tuber- 
cles, acting as foreign bodies, give rise to inflammation, 
usually of a chronic form, but sufficient to result in 
exudation of lymph, and the formation of adhesions be- 
tween the adjoining surfaces. Softening of the tubercular 
deposits sometimes takes place, and perforation of the 
intestinal wall results, leading to an effusion of the in- 
testinal contents into the peritoneal cavity. 

Cancer of the peritoneum, is sometimes seen as a primary 
affection, yet it more frequently extends to this membrane 
from some of the deeper parts. The encephaloid variety 
may be met with, but the colloid form is that most frequently 
seen. The omentum is the occasional seat of this form of 
cancer, the membrane in such cases becoming enormously 
increased in size. 

Tumors of various kinds, including fibrous, fatty, and 
cystic, may be found in the peritoneal cavity, general^ 
having had their origin, however, in the sub-peritoneal 
tissues. Fatty tumors may originate within the substance 
of the omentum or mesentary, while cystic tumors may be 
found within the broad ligaments of the uterus or ovaries. 



OF THE STOMACH. 137 



Section H. OF THE STOMACH. 

[Notice in examination: — 1. External characters — position; size; 
form; adhesions. 2. Contents-^qimntity, color, odor, reaction. Food — 
its nature, degree of digestion. Blood — pure or mixed with food; 
probable source. Foreign substances — powders, metallic particles, spirits, 
fcecal matter, bile, pus, worms. 3. Mucous membrane — general condi- 
tion of; color, soft or firm, rugae present or absent; thickness at various 
points; ulcers; their position, size, etc. 4. Muscular coat — thickness; 
visibility of fibres. 5. Entire walls — transparency ; wounds ; perfora- 
tions; ruptures; weight. 6. Condition of orifices — constricted; dilated. 
Tumors — position, size, character, etc.] 

Few organs of the body are subject to such a variety, or 
to such early post-mortem changes as the stomach, many of 
which, being closely simulative of the effects of disease, 
render a satisfactory examination of this organ, in many 
instances, very difficult. Therefore, before entering upon an 
account of the morbid anatomy of the organ, I shall briefly 
notice those changes which are post-mortem in their origin. 

The ordinary interval which intervenes between death and 
a post-mortem examination, is, in most instances, sufficient 
to seriously change the appearance even of the healthy 
stomach. Hence our knowledge of the healthy appearance 
of that organ, at least, previous to the experiments of Dr. 
Beaumont upon the stomach of Alexis St. Martin, was quite 
imperfect. 

Post-Mortem Changes. 

Among those changes taking place after death, which are 
no evidence of disease during life, may be mentioned: 

First. Appearances of Congestion. Very soon after 
death, or at least within ten or twelve hours, by gravitation 
of the blood, the same hypostatic congestion will be found in 
the most dependent portion of the stomach, that is seen in a 
more marked degree in the lungs, or in the subcutaneous 
tissues. 



138 PATHOLOGICAL CONDITIONS. 

Second. Coloring of Tissues. Not unfrequently, the 
tissue of the stomach will be found strongly tinged by color- 
ing matter of food or medicine, such as the red color of wine 
or logwood, or the black color of the metallic sulplmrets, etc. 

Third. Change of Shape and Size. Variations in the 
shape and size of the stomach from the normal standard, are 
not unfrequently found after death. It is sometimes found 
unusually small, apparently from the influence of the rigor 
mortis, the contraction necessarily resulting in increased 
thickness of the walls. What is known as hour-glass con- 
traction, although sometimes congenital in its origin, is fre- 
quently but a manifestation of the rigor mortis, when it may 
be distinguished from the former by inflation. Extreme 
dilatation, with thinning of the walls, is ajso sometimes seen, 
this condition resulting apparently from an absence of the 
post-mortem contraction. 

Fourth. Exfoliation of Epithelium. The stomach of 
young adults, dying of some acute disease, not unfrequently 
is found to have thrown off the epithelial layer of its 
mucous lining, even when the examination is made soon after 
death, and in cold weather. In many of the healthiest ani- 
mals slaughtered for food, the same change has been noticed 
as early as two hours after death. The detached cells are 
found floating in a thick mucus, the microscope also showing 
that the gastric follicles have thrown off their epithelial 
lining, with their pepsinous contents. With this change 
commences the post-mortem digestion of the stomach, to be 
soon noticed. 

The younger and healthier the subject, and the more acute 
the disease causing death, as a general rule, the more rapidly 
and effectively does this exfoliation take place. It may 
affect only the summit of the folds into which the mucous 
membrane is thrown by the contraction of the muscular 
coat, or it may uniformly involve the whole mucous surface. 

Fifth. Softening and Perforation. It is an interesting 



OF THE STOMACH. 139 

fact, that while the tissues of the stomach during life are 
unaffected by the gastric juice — the vitality of the tissues 
enabling them to resist its solvent power — after death, they 
immediately yield to its influence, and hence results a greater 
or less degree of softening of the coats, or even in some 
instances, complete perforation of the walls, the extent of the 
change depending upon the quantity of gastric fluid in the 
stomach at the time of death. In these cases there is, of 
course, no evidence of inflammation, while the tissues pre- 
sent a pulpy, gelatinous appearance, the walls being greatly 
thinned, and breaking down under the slightest force. In 
most instances, probably the actual perforation is the result 
of the force employed in lifting the stomach from its position. 
The opening in these cases is an irregular ragged hole, with 
soft, pulpy margins, and will more frequently be found at 
the large or cardiac extremity of the organ. 

In some extreme cases, the process of softening has not 
been confined to the walls of the stomach, but has extended 
to the adjoining organs, as the spleen, liver, or diaphragm. 

The whitish -gray and gelatinous appearances of these 
cases, will enable us to distinguish them from ordinary 
cases of softening and perforation from ulceration. 

This form of softening is especially observed in cases of 
sudden death immediately after a meal, while the stomach 
contains a large quantity of gastric juice. It is also seen 
much more frequently in children and young persons than 
in the aged, or those dying from chronic forms of disease. 
It has often been noticed in cases of consumption, however, 
which is to be accounted for upon the fact that many of 
these patients retain a good appetite to the last. 

Brinton, is of the opinion, that the solvent action of the 
gastric fluids upon the walls of the stomach, is promoted by 
the presence of vegetable or starchy food : — (1) by offering 
little substance upon which the fluids can expend them- 
selves ; and (2) by producing by its decomposition, an 



140 PATHOLOGICAL CONDITIONS. 

amount of acid, favoring an energetic action of the gastric 
fluids ; while on the other hand, the action of those fluids 
is retarded, (1) by the presence of alkaline saliva, or bile in 
any quantity ; and (2) by the presence of animal food upon 
which the juices may act. 

Case . — Perforation of the Stomach in a child two years of age- — 
death from Hydrocephalus. 

A child of Mr. T , in its second summer, had an attack of hydro- 
cephalus, finally dying in convulsions. The autopsy, made twenty- 
four hours after death, disclosed great congestion of the membranes of 
the brain, with two ounces of serum in the ventricles. Upon opening 
the abdominal cavity, all the viscera appeared healthy. In lifting the 
stomach from its position, a gush of colored fluid appeared from behind 
it, which at once led to the suspicion of a rupture. The whole organ was 
then carefully removed, when a ragged rent, through which the thumb 
could readily be passed, was discovered at the posterior portion of the 
cardiac end. The walls of the stomach at this point were extremely 
thin, soft and jelly-like; this condition being plainly the result of the 
post-mortem action of the gastric juice, while the rupture was the 
immediate consequence of lifting the organ from its position. 

Pathological States of the Stomach. 

Gastritis. Acute inflammation of the stomach rarely 
occurs, except as a result of some chemical or mechanical 
irritation. From the experiments of Dr. Beaumont, how- 
ever, we learn that the stomach is extremely liable to 
various grades of inflammatory action, which passing rapidly 
through their several stages, end finally in recovery. By 
watching the effects of excesses in the use of alcoholic stimu- 
lants, food, condiments, and of exercise after meals, etc., he 
observed that the pale, pink color, natural to the mucous 
membrane of the healthy stomach, was exchanged for a 
somewhat livid erythematous redness, which was distributed 
throughout the organ in irregular patches of various sizes, 
and in its most intense form, amounted to a kind of 
ecchymosis. 



OF THE STOMACH. 141 

Again, he noticed an excessive growth of epithelium, form- 
ing patches of false membrane like, which at various points 
appeared distended by an accumulation of a puriform fluid 
beneath, giving the appearance of little pustules. 

The following forms of gastritis are generally recognized : 

1. Catarrhal Gastritis. This, in its acute form, is sel- 
dom seen in post-mortem examinations. Chronic Catarrhal 
Gastritis, however, is by no means uncommon, and may be 
a result of the use of alcoholic drinks, the presence of 
various irritating substances taken either as food or medicine, 
and may attend many forms of chronic disease of other 
organs, or may be caused by obstruction to the circulation 
from disease of the heart, liver or lungs. 

The post-mortem appearances are neither very marked, 
nor constant. The mucous membrane may be found red, or 
of a dark color, thickened and sometimes roughened. The 
submucous and muscular coats may also be thickened, while 
less frequently, small ulcers may be found. 

2. Croupous Gastritis. This form is very rare, and 
seldom diagnosticated during life, but may be found with 
children who have died with croupous inflammation of the 
air passages, when small patches of false membrane may be 
found adhering to the mucous surfaces. It may be found in 
adults also, as an attendant of certain grave forms of disease, 
as typhus, puerperal fever, cholera, dysentery, or in death 
from irritating poisons. 

3. Phlegmonous Gastritis, is another very rare form of 
inflammation of the stomach, in which the disease involves 
all the coats, although originating in the submucous, and 
may destroy the patient in a few days with symptoms of 
peritonitis. The submucous tissues will be found filled 
with an exudation of a sero-plastic, yellowish substance, 
which produces thickening of the walls, and which may be 
confined to a portion or involve the whole organ. 



142 PATHOLOGICAL CONDITIONS. 

Effects of Poisons. The effects of caustic and other 
irritant poisons upon the stomach, as exposed by a post- 
mortem examination, will vary according to the nature of 
the substance, and the time it may have remained in the 
stomach. Redness in various degrees, and of various shades, 
ulceration, softening and perforation, may one or all, be 
detected in different cases. 

In large quantities, the mineral acids may leave the 
mucous membrane black, and of a soft, tarry consistence, 
readily breaking down upon handling the stomach. 

The peculiar action of the several poisons will be noticed 
in another place. (See Part IV.) 

Gastric Ulcer. Ulceration of the mucous membrane 
of the stomach, is much less frequent than of other portions 
of the intestinal canal, except as a result of the corrosive 
action of poisons.* A peculiar kind of ulcer, however — rare 
in this country, but said to be common on the Continent of 
Europe and in England — is sometimes found, which is of in- 
terest, from its occurring in tissues otherwise healthy, and 
often leading to a rapidly fatal termination. Rokitansky 
terms it the perforating gastric ulcer, from its marked ten- 
dency to perforate the walls of the stomach. It is situated 
in the region of the pylorus, and more frequently at the pos- 
terior surface and near the lesser curve. It is of a circular 
form, of three to six lines in diameter, and with as sharp 
edges as if a round piece of the walls had been punched out ; 
the edges being bevelled off, however, from within, leaving 
the peritoneal opening less than that in the muscular or 
mucous coats. Being usually situated near the lesser curve 
of the stomach, some of the larger blood-vessels are liable to 
become involved, giving rise to haemorrhage more or less 

* See Nos. 1309 and 1351 College Museum. 



OF THE STOMACH. 143 

severe. While but a single ulcer of this description is gen- 
erally found, two, three or more, may be present. 

A peculiarity of this form of ulcer, consists in its not being 
dependent upon irritation or inflammation, but rather upon 
a loss of vital assimulative power in the part affected . 

This form of ulcer may heal at any time previous to per- 
foration, and it is not uncommon to find a cicatrix in the 
mucous membrane of the stomach which has probably arisen 
in that way. 

Gastric ulcer is much more frequent in females than 
males, and is mainly a disease of middle and advanced 
life. 

Hemorrhagic Erosions. The appearance of the 
stomach, where there has been frequent vomiting of blood 
from this cause, is thus described by Rokitansky: "There 
are several roundish spots of the size of a pin's head or pea, 
or narrow elongated streaks at which the mucous membrane 
appears dark red, lax, soft and bleeding, and presenting a 
depression in consequence of loss of substance or slight 
erosion. This condition is invariably accompanied by haem- 
orrhage, the effused blood being mixed, in a more or less 
altered state, with gastric mucus. The erosions are often 
very numerous, studding, perhaps, every part of the stomach 
except the fundus, the pylorus being their chief seat." 

This condition of the stomach is not peculiar to any form 
of disease, or age, but is frequently associated with intemper- 
ance. It is rarely fatal, except by inducing some other 
lesion of the stomach, or by being united with some more 
general malady. 

Softening of the Stomach. We have already re- 
ferred to that form of softening of the stomach, which is 
•attributed to the action of the gastric juice after death. 
Another form is sometimes met with, which evidently takes 



144 PATHOLOGICAL CONDITIONS. 

place during life, and in most instances is attributable to a 
chronic form of inflammation. It is not always easy to dis- 
tinguish the two forms of softening without a knowledge of 
the previous history of the case. The distinction may, how- 
ever, generally be made by attending to the following 
points: — 1. The presence during life, of symptoms of disease 
of the stomach. 2. Appearances of congestion or inflam- 
mation, as well as softening, after death. 3. Extension of 
the morbid change to other portions than that affected by 
post-mortem softening, the latter being usually confined to 
the posterior portion of the cardiac end. 

Cirrhosis of the Stomach. In some obscure cases of 
gastric disease, upon opening the abdominal cavity in a 
post-mortem examination, we may at once notice a marked 
change in the appearance of the stomach. It presents a 
peculiar whiteness and opacity, an appearance which is 
partially due to a dulness of the peritoneal coat, in marked 
contrast with its usual brilliancy ; at the same time the 
organ may be either larger or smaller than the average size. 
Upon removing the organ, we find it greatly increased in 
weight and density, and presenting a hard, gristly feel, and 
with so much elasticity as to fail to collapse. An incision 
shows the walls uniformly thickened, to the extent of six or 
eight times their normal condition ; the whole organ is com- 
paratively bloodless, a condition strongly in contrast with 
the usual appearance after death. 

A close inspection of such a specimen, shows the several 
coats — muscular, mucous and fibrous — to be remarkably 
alike, the thickening and increased density, resulting from 
the presence of a generally diffused imperfect fibrous struc- 
ture, similar to that found in common fibrous tumors. The 
several coats of the stomach will be found unequally affected 
by this deposit. The submucous structure, as seen in a 
vertical section, being increased from ten to twenty fold, 









OF THE STOMACH. 145 

while the serous with the subserous may be increased seven 
to ten fold. The muscular tunic may be found from five to 
eight times its normal thickness, while the mucous mem- 
brane proper, is seldom more than double. 

Notwithstanding the bloodless character of the walls of 
the stomach in this disease, the abnormal condition is 
unquestionably the result of a chronic form of inflammation. 
The symptoms during life are usually obscure, and although 
the hard contracted stomach may form a sort of epigastric 
tumor, noticeable upon the surface, the absence of acute 
symptoms, with the age at which the disease makes its 
appearance — usually between twenty and thirty — permits 
of a ready distinction being made between this disease and 
cancer, with which it might otherwise be confounded. 

Atrophy of the Stomach. This condition of the 
stomach can hardly be looked upon as an independent 
malady, being rather an attendant of the general wasting of 
certain diseases, particularly of pulmonary consumption, 
marasmus, and starvation. The organ, in these cases, may 
be reduced to less than half its normal proportions, while its 
walls may be thinned and frequently softened. 

Dilatation of the Stomach, is another condition that 
can scarcely be considered as a primary affection. A great 
variation in the size of this organ is evidently compatible 
with health, large eaters having necessarily large stomachs, 
yet as the result of certain other morbid conditions, dilata- 
tion to an enormous extent may be induced. 

The following conditions may result in dilatation : 

1. Obstruction of the pylorus, as in scirrhus of that por- 
tion of the stomach. 

2. Destruction of a segment of the muscular coat by 
ulceration, or by becoming involved in a cancerous growth. 
Here the loss of contracting power, permits of a gradual 

10 



146 PATHOLOGICAL CONDITIONS. 

dilatation, from the inability of the segment involved to 
aid in carrying on the contents, their accumulation above 
this point aiding in the distension. 

3. An acute form of dilatation is sometimes met with, which 
can only be attributed to a paralysis of the muscular and 
secreting structures of the organ. It occasionally happens 
to a patient recovering from a fever. He has perhaps over- 
indulged in eating, as is not unfrequently the case with 
convalescents, and is suddenly seized with intense pain in 
the stomach, followed by rapid and great distension, and 
finally death. The autopsy discloses the stomach enor- 
mously distended, and its contents, including matters, in 
some cases, which were injested many days before. The 
mucous membrane appears but little changed, while the 
muscular coat is so thinned and stretched, as to appear like 
a scattered network of fibres. 



Morbid Growths. 

Cancer. This formidable disease occurs more frequently 
in the stomach, than in any other organ of the body, except- 
ing the uterus of the female. The disease is usually primary 
in this organ, but frequently springs up secondarily in other 
parts. 

The disease may occur in the three following forms— the 
scirrhus, medullary, and colloid ; while Dr. Brinton adds a 
fourth, the villous cancer of the mucous membrane. The 
usual seat of the disease is at the pylorus. It may involve 
a portion or the whole circumference of this opening, and 
from this extend along the lesser curve. In some cases, it 
commences at the cardiac orifice, and very rarely involves 
the whole organ, the fundus usually remaining free. The 
walls of the stomach may become greatly thickened in this 
disease, the inner surface tuberculated and roughened, and 
the cavity much diminished in size. When situated at the 



OF THE STOMACH. 147 

pyloric end, the disease seldom or never extends into the 
duodenum, but when at the cardiac, it generally involves 
the lower portion of the oesophagus. 

The fibrous or scirrhus form of the disease, is by far more 
commonly met with than any other, although it may be 
found occasionally combined with the medullary, or both 
these with colloid. Indeed, it is not improbable, but that in 
many cases, a growth originally scirrhus, becomes gradually 
converted into one of the other forms. 

In almost all cases, cancer commences in the submucous 
tissue, in the form of a dense mass, of a white color. When 
cut, the surface presents a whitish-gray appearance, con- 
trasting strongly with the vascular mucous membrane of the 
stomach, and presenting a distinctly striated appearance. A 
small portion under the microscope, or the juice scraped 
from the cut surface, will show the peculiar cancer cell, with 
granular matter. 

Encephaloid or medullary cancer, may be developed upon 
or within the fibrous form, or it may occur primarily as 
knotty tumors projecting through the mucous membrane. 
The miscroscopic appearance is much the same as in the 
fibrous variety, except that the cells are not so closely 
packed, bat are loosely held together by an abundant, soft, 
or liquid substance. 

The colloid form of the disease, may originate either in 
the mucous membrane itself, or in the submucous- tissue.. 
It is known by its presenting a tough, fibrous-looking, white 
tissue, which, arranged in intersecting bands, incloses irregu- 
lar spaces, which are filled with a clear, soft, or semi-liquid 
material, the proper colloid substance. 

The villous cancer, Dr. Brinton describes as arising in the 
basement membrane of the mucous coat, and as but a modi- 
fication of the epithelial cancer of other parts of the body. 

The mucous membrane covering cancerous growths, is 
subject to a variety of changes. It may become converted 



148 PATHOLOGICAL CONDITIONS. 

into a sort of fungoid growth, which at points suppurates, 
showing the submucous scirrhus tissue; or it gradually 
softens, giving rise to haemorrhages. 

The cancerous mass itself, may also soften or suppurate, 
resulting perhaps in perforation and peritonitis ; or adhesions 
may take place, followed by extension of the disease to the 
liver, spleen, pancreas, kidneys, etc. 

Cancer of the stomach, in the great majority of cases, 
occurs in persons 4 between fifty and sixty years, although it 
may appear as early as forty, or as late as sixty. Males 
appear to be more subject to the disease than females, in the 
proportion of four to three. 

The obstruction which the presence of cancer of the 
stomach is liable to produce, may result in one or more of 
,the following conditions : 

First, hypertrophy of the muscular coat. From increased 
'nutrition, the muscular fibres of the stomach may become 
-considerably increased in size and darker in color, thus 
•better enabling them to overcome the obstruction, which in 
-some cases, amounts almost to occlusion. 

Second, dilatation. This condition frequently attends the 
iformer, and indeed is seldom seen alone. It is confined to 
.those cases where the cancer is at the pylorus, and is more 
-.noticeable at the fundus of the organ. 

Third, contraction. This is seldom seen in connection 
with hypertrophy, and is far less common than dilatation. 
•Generally found in connection with cancer at the cardiac 
orifice, it may be looked upon as the result of the constant 
'.regurgitation which the obstruction produces, preventing thus 
the cavity of the organ from undergoing its normal disten- 
sion, by the presence of any quantity of food. 

Tumors. With, the exception of cancerous growths, 
tumors of the stomach are by no means common. 

Fatty tumors are sometimes met with, originating in the 



OF THE INTESTINES. 149 

submucous tissues, and as they increase in size, they may 
crowd either inwards towards the gastric cavity, or out- 
wards towards the peritoneum. 

Fibroid tumors, are also occasionally met with in the 
submucous tissues, generally in the line of the lesser curve, 
and about the cardiac orifice. 

Polypoid growths may also be found springing from the 
mucous surface, presenting the character of those formations 

usually. 

• 

Section 2. THE INTESTINES. 

[Notice in examination:— 1. External characters — displacements, 
as in hernia ; amount and condition of involved bowel. Invaginations — 
number, position and size; dilatations or contraction of intestines; 
apparent cause of. Peritoneal coat — inflamed or not ; adhesions ; their 
position, strength; perforations, etc. 2. Contents — gas; mucus; blood; 
pus; faecal matter; foreign substances, etc.; particulars in regard to 
each. Entozoa — number and character. 3. Mucous membrane — 
general condition ; congested, inflamed, ulcerated. Orifice of bile duct. 
Brunners glands — inflamed, enlarged or ulcerated. Peyer 's patches — 
number, situation, general condition, ulceration, etc. 4. Cazcum 
with appendix vermiformis — length, contents, ulcers, perforations, etc. 
5. Pedum — prolapsus, haemorrhoids, fistulas.] 

Malformations. The intestine is sometimes defective 
m some part of its course, most usually near its lower ex- 
tremity, and generally accompanied with an imperforate con- 
dition of the anus, [atresia ani.) This latter may be of 
various degrees, consisting sometimes in a simple closure of 
the anus by a continuation of the integument over it ; in 
other cases the rectum terminates in a blind pouch at a greater 
or less distance from the anus. 

Sometimes the intestine is unusually short, without any 
distinction as to size between the large and small intestines. 

It may terminate at the umbilicus, or in a cloaca common 
to it and the genito-urinary organs. 

Finally, it may consist of several detached ccecal portions. 

Andral notes the following malformations : — A single 



150 PATHOLOGICAL CONDITIONS. 

straight canal from the termination of the oesophagus to the 
commencement of the rectum ; a double duodenum ; two 
colons ; an unusually large, and at same time, double ap- 
pendix vermiformis. 

Diverticula are not unfrequent. They are ccecal append- 
ages, resembling the finger of a glove, one or more in number, 
varying in length from a few lines to several inches, and 
giving off at various points. Like the appendix vermiformis, 
they may become a source of danger by affording a lodge- 
ment for indigestible matters. 

In very rare instances the position of the intestines has 
been found completely transposed, with a corresponding 
transposition of all the abdominal viscera, or of only one 
organ. 

Inflammation. Vascular injection by itself cannot be 
taken as a decisive proof of the existence of inflammation. 
Obstruction to the free return of blood by the veins, during 
life, and the gravitation of blood to the most dependent 
parts, after death, especially after fevers, can and do pro- 
duce this very marked injection. In general, however, the 
smaller and more isolated the patch of injection is, the more 
likely it is to be inflammatory in its origin. 

Catarrhal inflammation may be either acute or chronic, 
and may either attack the mucous membrane uniformly, or 
be developed mainly in the villi and follicles. 

In the acute form : " There is more or less intense red- 
ness and injection of the mucous membrane, affecting its 
entire surface, or appearing as punctiform reddening from 
affection of the villi, or as a vascular halo surrounding the 
follicles ; relaxation of the tissue, and intumescence of the 
mucous membrane, equally affecting the entire surface, or 
only the villi and follicles ; opacity of the mucous membrane 
and its epithelium, from infiltration of the former and soft- 
ening of the latter ; friability and softening of the mucous 



OF THE INTESTINES. 151 

membrane. The submucous cellular tissue is injected, re- 
laxed and infiltrated with a watery opaque fluid ; the secre- 
tion is at first copious and serous ; as the affection increases 
in intensity it becomes opaque, viscid and puriform." 

In the chronic form, besides the above signs, we have also 
a dark, rusty, livid discoloration, sometimes pervading the 
entire mucous membrane ; the mucous membrane and its 
follicles are swollen, the tissue has become more dense, and 
the surface covered with an opaque, grayish- white, or puri- 
form mucus. Polypoid excrescences are sometimes found 
upon the mucous membrane. 

Both the large and the small intestines may be affected 
by catarrhal inflammation, although the chronic form seems 
to occur more frequently in the large. 

The muscular coat of the intestines is also sometimes the 
seat of inflammation, rarely if ever, however, as a primary 
disease, but by extension from the serous covering or mucous 
lining. 

Orouj)ous Inflammation. The mucous membrane is also 
subject to a chronic or sub-acute form of inflammation re- 
sulting in the production of an exudation much resembling 
that of croup. Sometimes it forms in a layer of some 
thickness, pretty uniformly over the surface, or appearing in 
the stools as tubular casts of the intestines ; sometimes it is 
very thin, or consists of mere shreds. The anatomical 
changes observed will be similar to those just noticed. 

Perityphlitis is an inflammation of the loose areolar tissue 
around the ccecum, occurring primarily or in consequence of 
typhlitis. If not checked, it ends in the formation of abscess 
in the right iliac fossa, which may discharge either into the 
neighboring viscera, or externally through the abdominal 
walls, mostly near Poupart's ligament. 

Peripractitis is an inflammation of the areolar tissue 
around the rectum. The resulting abscess discharges either 
externally, back of the anus, or in the perineal region, or 



152 PATHOLOGICAL CONDITIONS. 

internally into the rectum, or more rarely into the bladder, 
the vagina, the uterus, or into some other part of the 
intestines. Fistula in ano, frequently originates in this 
manner. 

Ulceration. Ulceration may occur as the result of in- 
flammations both catarrhal and croupous, and whether com- 
mencing in the mucous or the muscular layer, the ulcers may 
perforate the intestinal walls and give rise to an escape of 
the contents ; or the ulcers may cicatrize with the formation 
of the usual fibroid tissue, which, by subsequent contraction, 
may give rise to puckering or obstruction. 

In follicular ulceration of the colon, after lientery or 
tedious diarrhoea, the follicles are at first tumefied, and pro- 
ject as smaller or larger, round, conical nodules on the in- 
ternal surface of the intestine, surrounded by a dark-red 
vascular halo. Ulceration takes place in their interior ; an 
abscess with red, spongy walls appears ; the follicle is eaten 
away, and an ulcer of the size of a pea or lentil is formed. 
The mucous membrane is extensively destroyed, and with 
great rapidity. The disease is always confined to the colon, 
but when it runs a very rapid course, it may be accom- 
panied with catarrhal inflammation of the small intestines. 

Typhus ulcers. In continued fevers where the disease 
especially attacks the intestines, we find an ulceration of 
Peyer's patches and the solitary glands, which is called 
typhus ulceration by Rokitansky. and is thus described by 
him: — "After a preceding hypersemia around the solitary 
follicles, and in and around Peyer's patches, there is an 
enlargement of the glandular structures, followed by a 
softening and breaking down of the glandular mass. The 
cavity remaining on the mucous membrane after the dis- 
charge of this mass constitutes the typhus ulcer. Its form 
is elliptical, if a large patch has been destroyed; round, if 
a smaller patch or a solitary gland has been destroyed. 



KQ 



OF THE INTESTINES. 15, 

Partial destruction of a patch will produce an ulcer of 
irregular shape. The size varies also, according to the 
amount of ulceration." 

The margin of the ulcer is invariably formed by a well- 
defined fringe of mucous membrane, which is a line or more 
wide, detached, freely movable, of a bluish-red, and subse- 
quently of a slaty or blackish-blue color. The base of the 
ulcer is formed by a delicate layer of submucous tissue, 
which covers the muscular coat. The lower third of the 
small intestine is most liable to be involved in the ulcer- 
ative process, the number and size of the ulcers increasing 
as they advance toward the ileo-ccecal valve. 

Dysentery may also produce extensive ulceration of the 
colon, with considerable loss of substance. This loss may be 
repaired by cicatrization. In some cases, the cicatrix tissue, 
condensed into fibrous bands, forms projections into the cavity 
of the intestine, and not unfrequently encroaches upon its 
calibre in the shape of valvular or annular folds, giving rise 
to stricture of the colon. 

Dilatation. Disease of the nervous centres, inflamma- 
tion of its serous tissue, or simple atony of the muscular 
fibres, may be the cause of inaction of the intestine and 
consequent distension. Stricture will also produce disten- 
sion above itself, by an accumulation of the contents of the 
intestine. In these latter cases, the dilatation is often 
enormous. 

Contraction of the intestines may occur throughout a 
considerable extent, or in a very small part. 

In the former case, it results from the canal having been 
for some time empty, and is most likely to occur below a 
stricture. It can hardly be considered in itself a morbid 
condition. 

The second kind of contraction or constriction, is generally 



154 PATHOLOGICAL CONDITIONS. 

morbid, and may result either from external pressure bv 
tumor or otherwise, or from a disease of the tissue itself. 
The cicatrices of ulcers which have assumed an annular 
shape, are the most frequent causes of stricture originating 
in the intestine itself. 

Displacements. The most common of these constitute 
the various forms of hernia. 

1. Inguinal Hernia. Here the intestines escape by the 
inguinal canal, and it is Scrotal in man, when they descend 
into the scrotum, and Pudendal or Vulvar in woman, when 
into the labia majora. 

2. Crural or Femoral Hernia; when the intestines 
escape by the crural canal. 

3. Hernia at the Foramen Ovalis; when the viscera 
escape through the opening which gives passage to the 
obturator vessels. 

4. Ischiatic or Sciatic Hernia; when it takes place 
through the sacro-sciatic notch. 

5. Umbilical Hernia; when it occurs at or near the 
umbilicus. 

6. Epigastric Hernia; occurring through the linea alba, 
above the umbilicus. 

7. Hypogastric Hernia; when it occurs through the 
linea alba, below the umbilicus. 

8. Perineal Hernia ; when it occurs through the levator- 
ani and appears at the perineum. 

9. Vaginal Hernia ' ; occurring through the parietes of 
the vagina. 

10. Diaphragmatic Hernia ; when it passes through the 
diaphragm. 

A more detailed description of hernia belongs to works 
on surgery. 

A hernia, if not reducible, may, by becoming strangu- 
lated, give rise to constipation, hiccough, vomiting, and all 



OF THE INTESTINES. 155 

the signs of violent inflammation. Gangrene supervenes, 
with alteration of the features, small pulse, cold extremities, 
and death. 

Incarceration, is a form of mechanical obstruction of 
the bowels, differing from hernia, in there being no escape of 
the intestine from the abdominal cavity, as in the latter case. 
It may arise in various ways, but the most frequent form is 
that in which a portion of intestine becomes constricted by 
means of fibrous bands which have formed as a result of 
peritoneal inflammation. Passing from one portion of the 
intestines to another, or from the intestines to the abdom- 
inal walls, a loop of bowel may slip beneath or between 
these bands, and become so compressed, as to interfere with 
the passage of the contents, and result in great dilatation of 
the gut above the point of stricture. Complete strangulation 
may finally result, and the patient die with symptoms of 
mechanical obstruction. 

Another, but less frequent form of incarceration, is where 
a portion of intestine slips through the foramen of Winslow, 
or through a congenital opening in the mesentery, as in the 
following 

Case : — Death from Strangulation of the Bowel, from becoming 
Incarcerated in an opening in the omentum. 

Mary H , aged five years, was taken suddenly with great pain 

in the bowels at 2 o'clock A. M., having retired the night before 
in perfect health. Vomiting soon set in, accompanied with great 
thirst, and the whole body became bathed in a profuse cold perspira- 
tion. The severe pain continued, and the vomited matter became 
stercoraceous. I saw the case at 10 o'clock A. M., and then found the 
child in a moribund condition. The breathing was rapid ; pulse 
very small and frequent ; skin pale, damp and cold ; eyes sunken and 
nose pinched. Rapidly sinking, she died at 12 M. 

Autopsy twenty-four hours after death. Upon opening the abdomi- 
nal cavity, a large portion of the intestines was found of a dark purple 
or black color, while the remainder was perfectly natural in color. 



156 PATHOLOGICAL CONDITIONS. 

Upon lifting the bowels and exposing the mesentery, there was found 
an opening in the latter, of sufficient size to receive the thumb, and 
through which a large portion of the small intestines had become 
crowded, producing such a twist in the border of the mesentery as to 
have produced complete strangulation of the bowel, which had rapidly 
passed into a gangrenous state, resulting in violent shock and death in 
less than twelve hours. 

The opening was situated at about one inch from the intestinal 
border of the mesentery, and was plainly congenital in its origin, as 
indicated by its smooth and rounded edges.*" 

Another form of obstruction is sometimes found, and 
known as 

Volvulus, in which a loop of bowel, generally of the 
small intestines, becomes twisted upon itself, the constric- 
tion at the base of the loop, finally resulting in complete 
closure. 

Intussusception, or invagination of the bowels, consists 
in the slipping of a portion of intestine into itself, and gen- 
erally from above downwards. Either the large or small 
intestines may be found in this condition, but it is much 
more frequent in the lower portion of the small bowels. 
From a few inches to a foot or more of the bowel may thus 
become slipped into itself, and it may be found at more than 
one point. 

From the constriction which must necessarily attend such 
a displacement, congestion with haemorrhage may result, or 
peritoneal inflammation, gangrene, and death, with symp- 
toms of mechanical obstruction. In some rare cases, the 
inner or invaginated portion of the bowel sloughs off, adhe- 
sion takes place at the point of commencement of the 
intussusception, and the patient recovers. 

This form of displacement may be found in both children 

* See No. 1506, College Museum. 



0? THE INTESTINES. 157 

and adults, where the appearance of the parts are such as to 
render it apparent that it had not been a source of trouble 
during life. 

Rupture of the intestines may result from severe injury 
by blows, or from a crushing force applied to the abdominal 
walls. 

Penetrating wounds of the bowels may be followed by 
escape of the intestinal contents into the peritoneal cavity, 
acute peritonitis, and death. If the bowel be empty at the 
time, adhesions may form between the adjoining parts, the 
wound thus closed, and recovery follow. 

Prolapsus of the rectum consists in a protrusion of the 
mucous membrane or entire walls from the anus. The 
only post-mortem change that may be detected is a relaxed 
condition of the coats of the bowel, with congestion of the 
mucous membrane. 

Diseases of the Anus. These include ulcer and 
fissure of the anus, fistula in ano, and haemorrhoids. 

Ulcer, and fissure of the anus, usually accompany each 
other, though either may exist alone. The ulcer, when 
present, is found just within the anus, while the fissure 
extends from this across the edge of the sphincter. While 
these affections are trifling in their post-mortem appearance, 
they are of great importance from the local trouble and 
constitutional irritation which they may produce during life. 

Fistula in ano, consists in the presence of a false passage 
along side the rectum, usually the result of a small abscess 
in the ischio-rectal fossa. It is said to be complete when 
it opens at one end into the bowel, and at the other 
through the integument near the anus ; and incomplete, 
when it has but one opening, whether that be on the surface 
or in the rectum. 

Haemorrhoids will be noticed under the head of 



15S PATHOLOGICAL CONDITIONS. 



Morbid Growths. 

Cancer, in its various forms, may be found in connec- 
tion with the intestines, where it is usually primary in its 
origin. The scirrhus form is more frequently met with in 
the rectum, and is likely to involve the whole circumfer- 
ence of the passage. From the tendency which this form 
has to contract the parts, stricture of the rectum is likely to 
result, which may become a source of great suffering, and 
finally of death. Other forms of cancer may be found in 
any portion of the intestines ; the colon and rectum, how- 
ever, being their more frequent location. 

Cancer of the intestines is very liable to extend to the 
surrounding tissues and organs, and in many cases, perfora- 
tions of the bowel, or fistulous communications between the 
rectum and bladder in the male, or uterus or vagina in the 
female, may result. 

Tubercles, generally of the miliary form, may be found 
within the coats of the intestines, principally confined to 
the peritoneal covering however. They may occasionally 
be found in the mucous coat, and in the walls of follicular 
ulcers of that membrane. 

Tumors of various kinds may be found in connection 
with the intestine. 

Fatty tumors may originate within the mucous mem- 
brane, and project as polypoid growths into the cavity of 
the bowel ; or they may commence in the appendices 
epiploicse, and degenerate into a cystic tumor with fluid 
contents, or become infiltrated with calcareous matter ; or 
the pedicle may become atrophied and the tumor detached, 
and found free in the peritoneal cavity. 

Adenoid tumors may result from hypertrophy of the 
several forms of glands of the intestines, and appear as soft, 



OF THE INTESTINES. 159 

rounded, and perhaps pedunculated tumors, which are 
liable to become ulcerated. 

Fibroid tumors of small size and polypoid form, may be 
found in any part of the intestines, and are generally con- 
sidered as a result of chronic inflammation. 

Haemorrhoids or piles, consist in a dilatation of the veins 
of the lower portion of the rectum, with a thickening of 
their walls, and increase of surrounding fibrous tissue. 
They may be internal or external. The contained blood 
may coagulate forming a thrombus. The walls may rup- 
ture, giving rise to haemorrhages, or become inflamed and 
suppurate. 

Abnormal contents. The normal contents of the bowels 
may be found mixed with the various products of in- 
flammation, including mucus, serum, blood and pus. 

Biliary calculi and foreign bodies of various kinds, may 
be found, which may have produced no effects, or they 
may have served as nuclei, around which the salts of 
lime, bile, mucus, faecal matter, etc., may have accumu- 
lated, producing intestinal concretions. 

Parasites. The intestinal canal is infested by several 
forms of entozoa, among which may be found the following : 

Ascaris lumbricoides ; the common round worm, six to ten 
inches in length. It may be single or in large numbers. 

Oxyuris vermicular is ; a small white worm, measuring 
from two to four lines in length, and found only in the large 
intestines, and mainly in the lower part of the rectum, 
where they may be present in large numbers. 

Trichina spiralis. This parasite is found in the small 
intestine, and only in its adult form. It measures from less 
than a line, to two lines in length. The embryos penetrate 
the walls of the intestine, and finally locate in the muscles, 
where they remain encapsulated. If a portion of this muscle 
is eaten by another animal, the larvae again become active, 



160 PATHOLOGICAL CONDITIONS. 

and acquiring the mature sexual form, reproduce, the young 
embryos again migrating to the muscles. 

Tricocephalus dispar. Found only in the head of the 
colon, and measures one and a-half to two inches in length ; 
neck long, and body of male covered with wart-like append- 
ages on one side. 

Distoma lanceolatum. Flat, lancet-shaped, and trans- 
parent, a-half inch long, one-quarter wide. Rarely found in 
upper portion of small intestines, natural habitat appearing 
to be in the bile passages. 

Of tapeworms, the following varieties may be found : 

Tcenia solium. Head about the size of a pin-head, and 
furnished with sucking disk and double row of hooks ; neck 
long and narrow ; body flat and jointed, each segment 
about a-half inch in length ; body may be from ten to fifty or 
more feet in length. 

Tcenia mediocanellata. Head truncated and destitute of 
hooks ; body jointed and of great length. 

Tcenia fiavopuncta. Very rare. Yellow spot at the 
middle of each joint. 

Bothriocephalus lotus, (broad tapeworm.) Head long, 
unarmed ; neck inconspicuous ; body composed of about 
two thousand joints ; mature joints broader than long. 

Section IV. THE PANCREAS. 

[Notice in examination : — 1. External characters — malformations ; 
position; size; form; adhesions. 2. Substance— color ; consistence; 
wounds; abscess; tubercular deposits; cancer; cysts. 3. Ducts — 
calibre; contents; pus or blood, etc.] 

Anomalies of the pancreas are not common. It is 
wanting only in very imperfect monstrosities. Excess of 
development is very rare. 

Sometimes the duct is double, up to the point of its 
entrance into the duodenum. 



OF THE PANCREAS. 161 

Hypertrophy and Atrophy. The former, when it 
does occur, which is rarely the case, affects chiefly the 
cellular tissue which is interwoven with the glandular 
tissue. 

Atrophy often occurs spontaneously in old age, or it may 
result from chronic inflammation or fatty degeneration. 
The organ may be soft, or of a leathery consistence. 

Inflammation. The acute form rarely occurs, and is 
marked by the same signs of inflammation as are observed 
in inflammation of similar organs. 

" Chronic inflammation induces condensation, induration 
of the cellular tissue, obliteration of the acini, and either 
permanent enlargement, or subsequent atrophy of the 
gland." 

Fatty Degeneration is of frequent occurrence in 
drunkards, associated with fatty liver, but clue to the 
intrusion of the surrounding adipose tissue on the wasting 
organ. 

Dilatation of the ducts of the pancreas occurs from an. 
obstruction of its outlets by pressure of a tumor, or by the- 
presence of calcareous concretions. The dilatation may be 
uniform or saculated, forming cysts which may attain a 
considerable size. 

Cancer, only in the forms of scirrhus and encephaloid, 
affects generally the head of the pancreas. It may occur 
primarily or secondarily. The ductus choledochus is fre- 
quently obstructed by the pressure of the tumor, and' 
jaundice produced. The disease may extend to the duo- 
denum, the omentum, the mesentery, liver, and even the- 
suprarenal capsules and kidneys. As secondary cancer, : 
it is most frequently an extension from a scirrhus pylorus. 

11 



162 PATHOLOGICAL CONDITIONS. 

Section V. THE SPLEEN. 

[Notice in examination : 1. External characters — color, size, 
weight, form, adhesions; surface smooth or rough; capsule thickened, 
etc. 2. Substance — color; consistence; wounds; rupture; abscesses; 
tubercle; cancer; degenerations; tumors, etc.] 

Congenital Anomalies. In acephalous monsters the 
spleen is generally absent. Occasionally in subjects other- 
wise well developed, it is wanting, together with the stomach 
or the fundus of the stomach. 

Congenital displacements have been met with. 

Supernumerary spleens, varying in number and small in 
size, are frequently met with. 

Hypertrophy and Atrophy. Probably no organ of 
the body is as liable to such great variations in size as the 
spleen. The normal spleen in the adult, in whom it attains 
its greatest size, is usually about five inches in length, three 
to four in breadth, and an inch or an inch and a-half in 
thickness, and weighs about seven ounces. Its size is in- 
creased during and after digestion, and varies considerably 
according to the state of nutrition of the body. In typhus 
the spleen is enlarged, the parenchyma exceedingly soft, its 
color a dirty red, of different shades. In leuksemia it is also 
found greatly enlarged, but of a denser consistence. Roki- 
tansky states that the spleen not unfrequently measures 
sixteen inches in length, seven in breadth, and four inches 
in thickness, and its weight may amount to twelve or 
fourteen pounds, or, according to others, to twenty or even 
forty pounds. (Huschke.) 

Most of the hypertrophies of the spleen are accompanied 
not only by an engorgement of the very numerous vessels, but 
by an alteration and increase of the red, pulpy parenchyma. 

Atrophy may reduce the spleen to the size of a hen's egg 
or a walnut. It takes place normally in advanced age. 



OF THE SPLEEN. 163 

Displacements. Some of these are congenital : thus it 
has been found by the side of the bladder ; in the right side 
of the thorax ; in the left thoracic cavity when the dia- 
phragm was absent ; and external to the abdomen in large 
umbilical herniae, or where the abdominal walls had not 
closed. 

Other displacements are the result of disease. The 
enlargement or distension of adjacent parts, or increase in 
its own size with laxity of its ligaments, causes it frequently 
to be displaced, and even to descend into the pelvis. 

Rupture occasionally happens as the result of injuries. 
Spontaneous rupture in intense congestions during typhus, 
cholera, and the cold stage of ague, has occurred. This 
always proves fatal. 

Inflammation. Primary inflammation of the spleen is 
comparatively rare. Unless it ends in resolution, it gives 
rise to the formation of laudable pus or fibrin, which may 
either be contained in a circumscribed abscess, and thence 
become obsolete, or the cavity may enlarge until the pus 
penetrates into the left thoracic cavity, the stomach, the 
transverse colon, or the peritoneum. 

Secondary splenitis is regarded as identical with pysemic 
deposits. The deposits are well defined, always at the 
periphery, cuneiform in shape, the apex directed inwards. 
Their color is darker than the surrounding tissue, and their 
consistence firmer. They are either converted into a cellulo- 
flbrous callus, which contracts and causes a cicatrix in 
the surface ; or "into a puriform, creamy mass; or into a 
sanious greenish, greenish-brown, or chocolate-colored pulp." 
There are also fibrinous deposits frequently found in the 
parenchyma of the spleen, classed by some among the 
phenomena of secondary splenitis, but regarded by others as a 
simple exudation of fibrin, from an excess of this in the blood. 



16 i PATHOLOGICAL CONDITIONS. 

These deposits appear as a circumscribed yellowish mass, 
with a margin of darker or lighter red congestion of in- 
creased consistence, easily recognized when handling the 
part, " and showing under the microscope a confused mass of 
granular with more or less oily matter infiltrated among the 
remains of the parenchyma. They very commonly undergo 
fatty degeneration." 

Chronic Thickening of the Capsule of the spleen is 
of frequent occurrence. It seems to take place at the 
expense of the parenchyma of the organ, and may proceed 
to a very great extent. It is usually pretty uniform. Ossi- 
fication of the thickened fibroid layers is rare, except in old 
persons. 

Amyloid Degeneration of the Spleen. The dis- 
ease may be limited to the Malpighian corpuscles, consti- 
tuting the so-called " sago spleen," or it may extend and 
implicate the pulpy parenchyma between the corpuscles. 

The sago spleen is more or less enlarged ; its weight and 
density are increased. On section, the surface appears 
smooth, dry, and studded with glistening sago-like bodies, 
varving in size. An iodine solution gives them a reddish- 
brown color. 

In the more advanced stage, where the pulp is infiltrated 
with the new material, the organ generally is much larger 
than in the sago spleen. It is hard and firm ; the capsule 
tense and transparent. The cut surface is dry, homo- 
geneous, translucent, bloodless, of a uniform dark, reddish- 
brown color. The organ can be cut like wax. The 
corpuscles are obscured by .the surrounding pulp. 

Morbid Growths. 

Tuberculous matter is commonly deposited in the spleen, 
only in connection with general tuberculosis. It appears in 



OF THE LIVER. 165 

the form of gray granulations, miliary crude tubercles, or 
yellowish cheesy masses of various sizes. 

Cysts have been observed in the capsule of the spleen. 
They are small, of conical shape, and lightish red color, 
containing numerous granular cells, floating in a transparent 
liquid. 

Hydatid cysts may be found in the spleen alone, or at 
the same time with one in the liver. 

Cancer is rare. The encephaloid is the only form met 
with, and generally only with similar disease in the liver, 
stomach or omentum. 



Section VI. OF THE LIVER. 

[Notice: 1. External characters— relation to other organs and ex- 
tent uncovered by cartilages of ribs ; adhesions — their extent, position, 
firmness, etc. 2. After removal — weight ; measurements ; form ; color ; 
puckerings; rough or smooth; granulations; tubercles; cysts, etc. Cap- 
sule — thickness, transparency ; facility of removal ; appearance of liver 
substance beneath. 3. Internal structure — appearance of cut and frac- 
tured surfaces ; fluids expressible ; appearance of lobules ; abscesses ; 
fistulas; calcareous deposits; tubercles; growths; cysts; wounds; 
rupture, etc. 4. Gall-bladder — absent; size; shape; adhesions. 
Cavity — obliterated. Contents — bile ; quantity, color, consistence ; 
mucus ; pus, etc. Gall-stones — number, size, form, color, internal 
character. Walls — thickness ; deposits ; adipose or calcareous ; abscess ; 
tubercle ; cancer ; wounds ; rupture. Ducts — calibre ; dilated or con- 
tracted ; impervious ; from what cause ? contents ; condition of walls 
and mucous membrane.] 

The liver, in its normal state m the adult, will measure 
from ten to twelve inches in its transverse diameter, from 
six to seven in breadth at its widest part, and about three 
inches thick at the posterior border of the right lobe ; its 
weight being from three to four pounds. The gland is 
much larger in infants in proportion to the size of the body. 
In the adult, the average weight of the liver is but one- 
fortieth of that of the entire body, while in infancy, it may 
be as much as one-thirtieth or even one-twentieth. 



166 PATHOLOGICAL CONDITIONS. 

The natural color of the liver may be described as a 
reddish-brown or mahogany color, yet the shade may vary 
to a considerable degree in different cases. 

In studying the morbid anatomy of this organ, we shall 
notice first, changes peculiar to the liver itself, and secondly, 
those connected with the gall-bladder and gall-ducts. 

1. Diseases of the Liver. 

Congestion. From the large size and extensive distri- 
bution of vessels through the liver, this gland is capable of 
containing a large amount of blood, and in cases of retarded 
circulation in other parts, as in the recession of blood from 
the cutaneous vessels in a chill, the vessels of the liver may 
become greatly distended, constituting what is known as 
congestion. Although the gland is closely invested with 
the capsule of Grlisson, yet, the elasticity of this membrane 
will admit of considerable distension, and hence the great 
enlargement attending this condition of the gland. Conges- 
tion of the liver may be partial, confined to one or more 
lobes ; or general, involving the whole gland. It may also 
be active or passive. 

Active congestion of the liver may result from blows or 
injuries over the region of the gland, from suppression of 
heemorrhoid discharges, 'or suppression of the menses in the 
female. It will then be found presenting a deep red color, 
may be greatly increased in size, is more firm, and before 
opening the body, may be frequently felt below the margin 
of the ribs on the right side. 

One of the most frequent causes of passive congestion of 
the liver, is organic disease of the heart, accompanied with 
obstruction in the circulation through the lungs, giving rise 
thus to difficulty in emptying of the right side of the 
heart, and of the venous system general^. A chronic 
form of congestion of the liver may result from emphysema 



OF THE LIVER. 167 

of the lungs, large pleuritic effusions, or tumors within the 
chest, and is frequently found in persons of sedentary habits 
who have been "high livers," or in those who have used 
large quantities of alcoholic or fermented liquors, or in the 
residents of hot climates or malarial districts. 

Temporary congestion of the liver, although very extreme, 
does not result in structural change ; but when arising from 
a permanent cause, as disease of the heart, etc., it produces 
the following effects: — -"The distended capillaries of the 
portal-hepatic plexus press on the intervening cells ; these 
become in part atrophied or stunted ; in extreme cases 
almost destroyed ; in part they are gorged with yellow 
matter to such a degree that they appear as opaque masses. 
The quantity of yellow matter thus formed is far greater 
than any that exists in a healthy state of the organ, and as 
some of it is doubtless absorbed and carried into the blood, 
we find in this circumstance some explanation of the icteric 
hue which is so often observed in such patients. Whether 
long continued congestion produces still further changes is 
not yet made out clearly."* 

Extreme congestion of the liver may sometimes result in 

Hemorrhagic Effusion, the blood being either poured 
out near the surface, and dissecting up the capsule, or more 
deeply in the substance of the gland ; or, rupturing the 
capsule, it may escape into the peritoneal cavity. Such 
effusions may be found in new-born children after protracted 
and difficult labors, or as a result of external violence, and 
sometimes attend malignant fevers, scurvy, and purpura. 

Perihepatitis. The peritoneal covering of the liver, 
very, frequently in post-mortem examinations, presents 
appearances of having been attacked by inflammation, in 



Jones and Sieveking's Pathological Anatomy. 



168 PATHOLOGICAL CONDITIONS. 

the presence of bands of adhesion connecting different por- 
tions of the surface of the gland to adjoining organs. The 
whole of the upper surface will sometimes be found closely 
united in this manner, to the diaphragm. Such appearances 
are sure indications of the existence at one time/of an attack 
of peritoneal inflammation. In a cirrhosed condition of the 
gland, and over the seat of abscesses of the liver, such adhe- 
sions almost universally form. 

Inflammation of the peritoneal covering of the under 
surface of the liver, may result from an extension of the 
disease from an inflamed stomach or duodenum, or from 
the presence of a biliary calculus impacted in some of the 
ducts; such inflammation resulting in more or less exten- 
sive adhesion of the parts in contact. The presence of 
hydatid or cancerous masses, are not usually attended with 
these evidences of inflammation. 

Scar-like Marks, are not uncommonly found on the 
surface of the liver. The peritoneum at these points seems 
drawn into the substance of the gland, at the centre of the 
mark, while radiating ridges extend in various directions, to 
the distance of a-half to three-fourths of an inch. The cause 
of these appearances is evidently inflammation of the peri- 
toneum, extending to the subserous tissue, and perhaps to 
the liver substance. 

Hepatitis. Inflammation of the liver may be acute or 
chronic. 

Acute inflammation of the liver, though a frequent occur- 
rence in hot climates, is seldom met with in cold or tem- 
perate. The gland in this condition, is found more or less 
swollen and enlarged, and the tissues somewhat softened. 
This condition may be confined to one or more lobes, or 
involve the whole gland. Where a section is made, the 
turgid swollen tissue rises above the peritoneal covering, 



OF THE LIVER. 169 

along the edges of the incision. As the disease advances to 
a later stage, the deep red color changes to a brownish or 
grayish-red, patches of these being mingled with others of 
a yellowish-red or pale yellow. 

Acute inflammation of the liver may terminate in resolu- 
tion, when there will be a gradual restoration to a normal 
condition, or in suppuration, and the formation of an 
abscess/ the latter result being much more common. 

Abscess of the liver may involve the greater portion 
of the right or left lobe. The substance of the gland 
immediately around the abscess, will appear unusually red, 
and perhaps a little hardened, while other portions may 
present the appearance of health. In some instances, from 
a complete destruction of the hepatic tissue, the peritoneal 
covering will form the only protection to the contained 
matter. The quantity of purulent matter contained in these 
abscesses may vary from half a pint or less, to one or two 
quarts. 

The inflammation attending the formation of an hepatic 
abscess, will usually extend to the peritoneum, resulting in 
the formation of adhesions to the adjoining organs, and thus 
preventing the abscess, in many instances, from discharging 
into the peritoneal cavity, as it otherwise would be likely to 
do. Abscesses thus formed, may discharge: 1st, by the 
adhesive process through the diaphragm into the chest, and 
if adhesions had previously taken place between the dia- 
phragm and lung, by an extension of the ulcerative process, 
the matter may find its way into the bronchial tubes, and 
thus be discharged by expectoration ; 2d, by a similar 
process into the stomach, duodenum or colon ; 3d, upon the 
surface of the body; and 4th, within the peritoneal cavity. 
In the latter case, death is inevitable; in the others recovery 
is possible. The following case illustrates discharge and 
recovery by the first method : 



170 PATHOLOGICAL CONDITIONS. 

Case. — Abscess of the Left Lobe of the Liver, discharging through 
the diaphragm, a portion of the matter expectorated, the balance 
discharged upon the surface of the body — Recovery. 

In the winter of 1856-7, I was called to see Mrs. B , aged 40, 

of Broad street. She had been given up by the physicians previously 
in attendance. Found her greatly emaciated, suffering from a terrible 
cough, and expectorating great quantities of excessively offensive matter. 
Diarrhoea, hectic fever, night sweats, with occasional chills, completed 
the picture, and appeared to render the case perfectly hopeless. Upon 
inquiry, learned that she had been taken ill some months previously, 
with what the attending physician had pronounced as acute hepatitis. 
After the usual acute symptoms, the formation of an abscess became 
evident from the fulness in the region of the left lobe, accompanied 
with chills, hectic, etc. A violent cough, with evidences of inflamma- 
tion in the left lung, accompanying the other symptoms, the case was 
supposed to be complicated with tuberculosis. The expectoration 
finally became greenish, thick and exceedingly offensive, indicating 
that the abscess had worked its way into the bronchial tubes. In 
examining the chest, after the case had been under my care a few 
days, I noticed between the ninth and tenth ribs a fulness and slight 
redness. After the application of poultices for a few days, a distinct 
"pointing" appeared, from which, after the use of the lance, came a 
most copious discharge of the same green, offensive matter, as was 
being discharged by expectoration. From this time, a slight improve- 
ment was noticed in the patient. The external opening was carefully 
kept from closing. The cough gradually improved. Little or none of 
the offensive matter was raised after the establishment of the external 
opening. In six months the health was fully restored, and now» 
fifteen years after, she is a stout, healthy woman. 

In the progress of formation of an abscess in the liver, as 
branches of the portal or hepatic veins are reached, inflam- 
mation of their coats is excited, which results in their obliter- 
ation, thus generally preventing the admission of pus into the 
venous system. But as the enlarging abscess encroaches 
upon the hepatic ducts, instead of these becoming closed by 
inflammation, they ulcerate through, and thus establish a 
communication between these vessels and the cavity of the 
abscess. Hence the pus contained in these abscesses, is 
very likely to be mingled with more or less bile ; while at 



OF THE LIVER. 171 

the same time, a portion of the contents may be discharged 
through the common duct into the bowels. 

Abscess of the liver may result from inflammation and 
ulceration of the bile ducts, from the irritation of impacted 
calculi, or from the presence of intestinal worms that have 
entered by the ductus communis ; or from the lodgment of 
emboli in some branch of the portal vein or hepatic artery. 

Secondary, Pyaemic or Metastatic Abscess. The 

liver is occasionally the seat of abscesses forming as a result 
of pycemia, induced by absorption of pus from some wound 
of a joint, vein, or bone; or from a diffused abscess or 
erysipelas of the skin. These abscesses usually contain a 
somewhat thin and oily-looking pus. They also differ from 
ordinary abscesses in the rapidity with which they form, a 
few days generally sufficing to give them a large size. The 
insidious manner in which they form — the tissues breaking 
down, as it were, without any inflammation — constitutes a 
distinguishing feature of these collections. Pysemic abscesses 
of the liver are usually many in number, and varying in 
size from a pea to that of a walnut. The gland is usually 
enlarged at the same time, and in some cases to such an 
extent as to reach quite to the umbilicus. This form of 
abscess is not confined to the liver, but may be found in the 
lungs, spleen, in the joints, or in the serous cavities, and 
sometimes diffused through the connective tissues and 
muscles of the limbs or trunk. 



Degenerations of the Liver. 

Waxy, Lardaceous, or Amaloyd Liver. In this 
form of disease, the liver undergoes greater enlargement 
than in any other disease excepting cancer. The enlarge- 
ment is uniform in every direction, so that the form of the 
gland is unchanged. Pain and tenderness are never promi- 



172 PATHOLOGICAL CONDITIONS. 



>e 



nent symptoms of this disease, hence the liver may 1 
manipulated during life with impunity, the patient com- 
plaining only of weight and tightness in the right hypo- 
chondrium. 

The progress of the disease is usually slow, extending, in 
most cases, over several years. The spleen, kidneys and 
intestines will frequently be found presenting this change at 
the same time. 

The tissue of the gland in these cases is very firm, so that 
the organ generally retains its form when laid with its con- 
vex surface on the table. The external surface is smooth 
and free from adhesions. When cut, a peculiar translucent 
substance is found infiltrated through the tissues, giving it a 
firm, glistening appearance, known as waxy, lardaceous, 
amaloyd, albuminous, or sometimes scrofulous liver. This 
substance is stained a deep red by the action of a weak 
solution of iodine. 

The change appears to commence first, in the small blood- 
vessels, finally extending to the lobules, appearing first in 
the centre, and ultimately involving the whole lobule. 

The disease is more common in males than females, and 
is frequently caused by constitutional syphilis. In some 
instances, it would appear to be produced by a tubercular 
diathesis, and co-exists with some local form of scrofulous 
disease, or by a long exposure to malarial influences. 

Fatty Liver. This form of disease we find in drunk- 
ards ; in persons who have been large eaters and sedentary 
in habit ; in several wasting diseases, as in chronic diarrhoea, 
and especially in phthisis pulmonalis. There is a moderate 
degree of enlargement which affects all portions of the gland. 
The consistency is softer, and the resistance less than in 
waxy liver, giving it a doughy feel. The color varies, but is 
usually lighter than normal, approaching a yellow, and more 
or less mottled. When cut, the substance presents a deci- 



OF THE LIVER. 173 

dedly oily appearance, both to the feel and sight. The 
disease is unaccompanied with pain from first to last; 
neither is its function materially interfered with, hence 
jaundice is not usually a symptom of the disease. 

A microscopic examination shows the lobules of the liver 
filled with fat globules, which appear to have originated in 
the hepatic cells. The change appears to commence at the 
circumference of the lobule, the centre remaining normal in 
color, thus giving a mottled appearance to the cut surface. 

Other organs are very liable to be affected at the same 
time by this form of disease, as the heart, kidneys, etc., the 
symptoms which the case presents, such as albuminous 
urine, tendency t£> dropsy, dyspnoea, etc., arising from these 
organs, rather than from the fatty liver. 

Pigmentary Degeneration. In cases of malarial 
poisoning, we sometimes find the liver with other organs of 
the body, as the spleen, lungs, brain, kidneys, etc., present- 
ing a peculiar dark color, the result of the presence of a 
black or brown pigment in the blood, filling the vessels of 
these organs. The pigment appears to be formed of small 
granules either free or contained in irregular cells. In the 
liver, this pigment is found most abundant in the blood of 
the portal vein, but may be present in the hepatic artery, 
and in all the venous capillaries. 

The liver may be normal in size, or it may be atrophied or 
hypertrophied, or may have undergone fatty or waxy de- 
generations. 

Granular Degeneration. A peculiar change in the 
liver substance is sometimes found after death from various 
acute or infectious diseases, as the exanthemata, pyaemia, 
septicaemia, erysipelas, typhus, typhoid, and yellow fever, 
etc.; or from thrombosis of the portal vein, abscesses or 



174 PATHOLOGICAL CONDITIONS. 

cirrhosis, as well as in poisoning by arsenic, phosphorus or 
antimony. 

The change in the early stage consists in an accumulation 
in the liver cells, of a fine granular substance, soluble in 
alkalies, and apparently of an albuminous nature; and, at a 
later stage, of coarser shining particles of a fatty character, 
and soluble in aether or alcohol. 

Atrophy of the liver may be divided into the following 
forms : 

I. Simple Atrophy. 

II. Acute or Yellow Atrophy. 

III. Chronic Atrophy, or Cirrhosis. 

Simple Atrophy. By this, we understand a diminu- 
tion in the size of the liver, without any alteration in its 
structure. In this state, the liver may be reduced to one- 
half its normal weight and bulk. It is found to occur : 

1. Old age. Hence this form of atrophy is sometimes 
called " senile atrophy." With the loss of adipose tissue in 
advancing years, there is also a tendency either to degenera- 
tion or wasting (atrophy) of many of the organs, and 
especially of the liver. In this manner, the liver may be 
reduced to one-half its normal size and weight without any 
change of structure. 

2. Inanition, arising either from an insufficient supply of 
food, or from diseases which interfere with the assimilation 
of food, may result in simple atrophy of the liver. 

3. External pressure may also produce the same result, 
as from tight lacing, pleuritic, pericardial, or peritoneal 
effusions, or from enlargement of organs, or presence of 
tumors near the liver. 

Simple atrophy is rarely attended with jaundice unless 
pressure upon the bile ducts has been such as to obstruct 
the flow of that fluid. 






OF THE LIVER. 175 

Acute, or Yellow Atrophy. In this somewhat rare 
form of disease, the liver becomes rapidly atrophied, accom- 
panied with jaundice and cerebral symptoms. After death, 
the organ is found greatly reduced in size, extremely soft 
and yellow, with no appearance of lobules, and upon micro- 
scopic examination, the secreting cells found more or less 
changed into granular matter and oil globules. The weight 
of the gland in these cases, may be reduced from three to 
four pounds, the average normal weight, to less than two 
pounds. 

This form of disease is frequently attended with haemor- 
rhages, particularly of the stomach and bowels, and in some 
instances, from the uterus or nose. 

Pregnant females suffering from this affection usually 
abort. 

Among the causes of this form of disease of the liver may 
be mentioned pregnancy, dissipation, constitutional syphilis, 
malaria, and the blood-poisoning of typhus fever. 

Females appear much more liable to the disease than 
males, and most persons attacked are under middle age. 

Chronic Atrophy, Cirrhosis or Hob-nail Liver. 

The form of atrophy of the liver which we now have to 
consider, is slow in its progress, and is usually associated 
with abdominal dropsy. The appearance and density of the 
gland varies to a considerable extent in different cases of 
chronic atrophy, yet the usual appearance is that seen in 
what is known as cirrhosis,* or " hob-nail liver," also some- 
times called "gin-drinker's liver." Here the liver has 

* Cirrhosis, as applied to this condition of the liver, has reference to 
the yellow color, due to the presence of large quantities of yellow 
pigment contained in the secreting cells; hence the application of the 
term to diseases of the lungs, kidneys, etc., which resemble cirrhosis of 
the liver, not in color, but in density of the tissues, is obviously 
inappropriate. 



176 PATHOLOGICAL CONDITIONS. 

become reduced in size, from a slow destruction of the 
secreting tissue, while, at the same time, the fibrous tissue 
of Glisson's capsule has become thickened and hardened, 
from a chronic inflammatory action, often clue to the use of 
spirituous liquors. The outer surface presents a granular or 
nodulated character, which has given rise to the term "hob- 
nail," as applied to this disease; while, upon section, the 
interior presents firm fibrous bands, surrounding yellow 
patches of secreting tissue. While, in the majority of cases, 
this disease is plainly owing to an abuse of spirituous 
liquors, in others, it is found associated with, disease of the 
heart, or with constitutional syphilis, where the patient has 
been strictly temperate. 

The increased density, in connection with the diminution 
of size, and granulated character of the surface, renders the 
disease readily recognizable in a post-mortem examination. 

The early stage of this disease appears to be accompanied 
with a degree of enlargement of the gland, resulting from' 
the congestion attending the inflammation of the fibrous 
structure. As this structure increases in density, by press- 
ure it causes a gradual absorption of the secreting lobules, 
and thus results in a reduction in the size and weight of the 
organ. 

The secreting cells of the lobules of the liver, may 
undergo fatty change, or they may become entirely de- 
stroyed. Thrombi may be found in the portal vein. The 
hepatic artery and its branches become increased in size, 
while the interlobular hepatic veins become quite destroyed. 
The obstruction to the circulation through the liver, result- 
ing from these changes, gives rise to the dropsical effusions 
usually found in this disease. 

Prominent among the symptoms attending this disease, 
during life, may be mentioned : — 1st. Diminished area of 
hepatic dulness. 2d. Ascites, particularly in advanced 
stages of the disease, although patients may die before 



OP THE LIVER. 177 

dropsy sots in. 3d. Enlargement of the spleen — this being 
present at least in about one-half the cases. 4th. Enlarge- 
ments of the superficial veins of the abdomen, from ob- 
structed flow of the portal blood, or from pressure upon the 
vena cava, from abdominal distension. 5th. Haemorrhoids, 
epistaxis, hsematemesis, etc. 6th. The rare occurrence of 
decided jaundice. 7th. In all cases, the advance of the 
disease is marked by progressive emaciation and debility, 
the patient usually dying of exhaustion, although in some 
cases death is due to an attack of pneumonia, oedema of the= 
lungs, or acute peritonitis. 

Hypertrophy. We sometimes find an evident increase 
in the size of the liver, without any alteration of structure, 
or the presence of any prominent symptoms. Such cases^ 
may be considered as instances of simple hypertrophy. 
This condition has been observed in cases of leukaemia, and 
in some exceptional cases of saccharine diabetes, heart disease- 
and phthisis. 

Morbid Growths* 

Cancer of the Liver, Every variety of cancer may 
be found in the liver, though the scirrhus or medullary 
forms are more common. The disease is invariably accom- 
panied with enlargement, and in some instances the increase- 
is enormous. The progress of the disease is rapid, a few 
weeks in many instances, a few months at the longest,, 
being required to fully develop the disease. The enlarge- 
ment is not uniform. The surface becomes irregular and 
uneven, nodules of various size are found projecting from its 
surface and borders, which are usually harder than those of 
the surrounding portions. The disease is nearly always: 
accompanied with pain, and considerable tenderness is felt 
upon touch. 

12 



178 PATHOLOGICAL CONDITIONS. 

Jaundice is present in many cases, but in ninety-one cases 
collected by Freriehs, fifty-two showed no symptoms of 
jaundice. Abdominal dropsy to any considerable extent, 
rarely attends the disease, although usually a small quantity 
of fluid will be found in the peritoneal cavity. These char- 
acters will usually enable us to make a correct diagnosis of 
these cases during life. 

The post-mortem examination, discloses, in the majority 
of cases, a greater or less number of irregular, rounded 
masses, projecting from the surface of the liver, and vary- 
ing in size from a kernel of corn to an orange. Through 
the peritoneum, these bodies present a light, straw-colored 
appearance, and when divided, the interior is found of a 
whitish-gray color, and of the consistence of tallow or 
cheese. Examined very carefully, the substance has the 
appearance of infinitely minute granules, aggregated to- 
gether. 

These masses may be confined to one of the lobes, or 
involve the whole organ ; they are of an irregularly rounded 
or globular form, and in some cases two or three appear to 
have coalesced into one mass. 

In other, and more rare cases, the cancerous matter, 
instead of being collected in masses, is found more or less 
infiltrated through the liver substance, as in Case I. 

They may soften, and form cysts filled with a thin serous 
fluid, or they may undergo a form of fatty degeneration. 

In such cases the disease is liable to be mistaken for 
waxy degeneration. In .both, there is a uniform hard 
enlargement, but in the waxy enlargement, the progress is 
slow, and without pain, and there is usually enlargement 
of the spleen, with albuminuria, and a syphilitic taint ; while 
in cancer there is no enlargement of the spleen, or albumi- 
nuria, and the course of the disease is rapid ; there is pain, 
cachexia, and often signs of cancer elsewhere. 

Cancer of -the liver, in the majority of instances, is 






OF THE LIVER. 179 

secondary to cancer of some other part, as of the stomach, 
rectum, or female breast. In more than one-third of the 
eases, it is said to he secondary to cancer of the stomach. 

Cases are rare where the liver is primarily affected with 
cancer. Before thirty-five or forty years of age, secondary 
cancer seldom occurs. 

The following cases will serve to illustrate the two forms 
of cancer of the liver : 

Case I. — Primary Cancer of the Liver, with great enlargement — - 
Rupture of Stomach from post-mortem softening. 

Mrs. K . aged 38, light complexion, short and fleshy, commenced 

complaining about New Year's, 186S, of pain in the " stomach," as she 
expressed it, with loss of appetite, restlessness at night, accompanied 
with weakness and prostration. These symptoms continued for a couple 
of weeks, when she commenced to complain of soreness in stooping, and 
inability to wear her clothes tight. This led to an inspection of the 
abdomen in bed. I then found projecting below the margin of the 
chest on the right side, a hard rounded tumor, nearly of the size of the 
fist, somewhat sensitive to the touch, and evidently springing from the 
liver. The pain daily increased in severity, and coming on as it did, 
in paroxysms, resembled much the pain attending the passage of 
biliary calculi. 

After she took to her bed, which was in the latter part of January, 
there was a rapid increase in the size of the liver, with a marked 
aggravation of all the symptoms. The pain was most agonizing; 
slight chills occurred from day to day ; the flesh rapidly wasted, and 
the outline of the lower border of the liver could be distinctly traced 
through the abdominal walls. There were no symptoms of jaundice. 
The skin was pale and waxen in hue. In the latter part of Feb- 
ruary, frequent epistaxis, and bleeding of the gums set in, while from 
the pressure upwards upon the diaphragm, the lungs were so embar- 
rassed as to give rise to great dyspnoea. Rapidly sinking, she died on 
the first of March. 

Autopsy, made thirteen hours after death. Anterior portion of the 
body pale ; posterior dark from gravitation of the blood. Rigor 
mortis scarcely noticeable. Upon opening the abdomen, found four to 
six ounces of serum in the peritoneal cavity. 

The liver was enormously enlarged, filling a great portion of the 
abdominal cavity, pushing the diaphragm high up into the chest, and 



180 PATHOLOGICAL CONDITIONS. 

giving the lungs less than half their normal amount of room for expan- 
sion. The upper surface of the right lobe was found adhered to the 
under surface of the diaphragm, and to the anterior abdominal wails, 
and the under surface to the stomach, duodenum and transverse colon. 

The surface of the liver was dark, mottled, and somewhat nodulated. 
The whole gland was quite firm, yet evidently just entering upon 
a softened stage at numerous points. No trace of an abscess forming 
at any point. 

Upon lifting the left lobe of the liver, a dark, brownish fluid 
appeared behind the stomach, the origin of which was not at first 
apparent. The removal of the liver, however, completely exposing 
(he stomach, showed the posterior wall at the large end, softened and 
ruptured. This softening was evidently a post-mortem action of 
the gastric juice; the rupture resulting from the tension upon the 
same, in tearing away the adhesions between the stomach and liver. 

Upon the removal of the liver, found it to weigh eighteen pounds. 
The gall-bladder was empty and contracted. The only portion of the 
gland not involved in the disease, was one of the small lobes, the lobus 
Spigelii, and a portion of the left lobe. Incisions, showed the interior 
presenting a similar mottled appearance as the surface ; dark, almost- 
black spots, intermixed with spots of brown and gray. The blood- 
vessels of the liver were enlarged, and filled with dark defibrinated 
blood. No trace of coagulated blood, in anv of the blood-vessels of 
the body. 

Microscopic examination. An examination of a small portion taken 
from the right lobe, with a power of 350 diameters, showed innumera- 
ble cells of an irregular outline, and varying in size ; oil globules, and 
granular matter. The action of acetic acid, rendered the nuclei of 
the cells faintly visible. Many cells of a large size were found filled 
with a growth"' of smaller ones. All other organs of the body normal.* 

Case II. — Cancer of the Liver, secondary to Cancer of the Rectum, with 
diffused Abscess in the Neck. 

Mr. A , of Doylestown, Pa., aged 60, had been suffering for 

some months with symptoms of disease of the rectum, with also inflam- 
mation of the bladder. His passages were painful, and accompanied 
with more or less bloody, purulent matter. His urine was thick, at 
first from presence of large quantities of mucus, later of pus. His 
appetite and digestion were poor ; his color pale and cachectic. 

Some six months previous to death, he commenced passing with his 

* See No. 1495, College Museum. 



OF THE LIVER. 181 

urine, small quantities of seeds of berries, tomatoes, ete. These grad- 
ually increased in quantity, until, for some weeks previous to death, 
there was a tree discharge of feculent matter from the bladder, and at 
the same time much urine passed- per rectum. A low days before 
death, there appeared a diffused swelling upon the front of the neck, 
extending from the clavicles as high as the upper portion of the 
larynx. There was no discoloration of the surface. The swelling pre- 
sented a boggy feel, without any positive fluctuation. 

On 'the 15th of July, 1871, I was called by Dr. George Wright, who 
had been treating the case for the past year, and from whom I learned 
the above facts, to make a post-mortem examination, the patient 
having died the day before. 

Found the body very thin, surface pale. No serum in the peri- 
toneal cavity. Upon lifting the small intestines from the cavity of the 
pelvis, found the rectum closely adhered to the posterior surface of the 
bladder, completely obliterating the recto-vesical cul-de-sac. Consid- 
erable dense scirrhus matter, was found upon either side of the rectum 
and bladder. 

Upon removing the rectum and bladder, a large opening (one inch 
in diameter) was found communicating between the two. The edges 
of this opening were thick and ragged. The walls of the bladder and 
rectum generally, were thick and hard from scirrhus deposits. The 
bladder contained considerable purulent and feculent matter, with also 
a cherry-stone. Upon examining the liver, found upon the under 
side of the left lobe, a large cancerous mass, imbedded in the substance, 
but projecting from the surface, and quite as large as a goose egg. 
Other portions of the liver healthy. * 

The lungs were healthy. The muscular walls of the heart were pale 
and soft, while each of the cavities contained soft, imperfectly formed 
fibrinous clots. 

The right pleural cavity contained nearly a pint of serum, while the 
pleura presented a red, inflamed appearance. 

In removing the sternum from its position, noticed purulent matter 
beneath the upper end, which appeared to come down from the neck. 
Upon carrying an incision upwards to the hyoid bone, found the whole 
region of the neck infiltrated with pus, without being confined by any 
limiting membrane or sac, and evidently metastatic in its origin. 

Tubercles. The peritoneum covering the liver, like 
other portions of this membrane, will sometimes (more 

* See No. 1496£, College Museum. 



182 PATHOLOGICAL CONDITIONS. 

frequently with children) be found filled with numerous 
minute tubercular particles, the presence of which are liable 
to give rise to appearances of inflammation, such as redness, 
roughness, and perhaps adhesions. 

Fibroid and Cartilaginous Tumors are of extreme 

rarity in the diver. When present, they exhibit the charac- 
ters of those growths in other parts. 

Adenoid Tumors have been detected in this gland. 
They vary in size and number, but are usually enclosed in 
a fibrous capsule, and appear to be made up of glandular 
cells, resembling the hepatic cells, but of larger size and 
greater density. 

Vascular Tumors are sometimes found in the liver, 
consisting apparently of a compact, irregular network of 
dilated veins, held together by connective tissues. Of a 
dark, almost black color, they vary in size from a few lines 
to two or three inches in diameter, and are very irregular 
in their outline. 

Cysts of small size are occasionally found, developed 
either in the connective tissues, or from a dilatation of bile 
ducts. They may be found filled with serum, or colored 
mucus and epithelial cells. 

Syphilitic Tumors, from the size of a pin's head to that 
of the fist, may be found in the liver. They are of a gray, 
whitish or yellow color, made up of cells of an irregular 
form, which show a tendency to cheesy degeneration, or to 
such softening as to give the appearance of an abscess. 

Blood-vessels of the Liver. 

The hepatic artery is sometimes found with aneurismal 
enlargements, and rarely contains an embolus. 



OF THE LIVER. 183 

The port< il vein is frequently found containing a fibrinous 
clot, constituting thrombosis. Such clots may result from 
pressure on the vein from the presence of some morbid 
growth in the liver, or from a tumor in the mesentery or 
some other part, obstructing the portal vein below the liver ; 
or from suppurative disease or ulceration of the several 
organs from which the portal vein arises. They may be a 
cause, or result, of phlebitis, and may give rise to jaundice, 
and sometimes to abscess of the liver. 

Dilatation of the portal vein may result from obstruction 
of the capillaries of the liver in chronic atrophy or cirrhosis; 
or from the presence of thrombi, or pressure by various 
morbid growths. 

Calcification, not only of the portal vein within the liver, 
but of its various branches of origin within the mesentery, 
omentum, etc., may occasionally be met with.* 

The hepatic veins may be found presenting the same 
abnormal conditions as the portal vessels. 



Animal Parasites. 



The liver has long been known as a favorite resort for 
different parasitical animals, the most common of which, is 
that of the larval form of one of the tapeworms — the Tamia 
echinococus — constituting when developed in the liver, what 
is known as an acephalocyst or hydatid. 

Hydatid Tumors of the liver, arise in the following 
manner: — The several tapeworms pass through three stages 
of development, these never being completed however in the 
same animal. The Taenia echinococus, acquires its adult 

* See report of case of "Ossification of Veins," by James Kitchen, 
M. D., in American Journal of Homoeopathic Materia Medica for 
December, 1871, page 143. 



184 PATHOLOGICAL CONDITIONS. 

form, only in the intestines of the dog or wolf. The mature 
segments, each of which are filled with vast numbers of 
eggs, are voided with the fasces, into which the eggs are 
discharged. These soon develop into a minute embryo, 
with one extremity provided with numerous little hooks. If 
taken into the stomach of an herbivorous animal or man, 
this embryo, pierces the walls of the intestines, enters a 
blood-vessel, and finally lodges in some of the tissues or 
organs, more frequently the liver, where it develops into 
a sac-like body, known as a cysticercus or hydatid, the 
second larval form. When the embryo is taken into the 
stomach of other animals, no further development takes 
place. 

While in the hydatid, or second larval form, by a peculiar 
process known as alternate generation, there may be a 
reproduction of cysts to an almost endless extent within the 
parent cyst, or secondarily in other parts. 

The adult or third stage of development, can only be 
attained within the intestinal canal of the dog or wolf. 
These animals devouring a sheep or other ruminant, or 
in some rare case perhaps a human being, within which 
the hydatid has been formed, the cysts thus taken into the 
stomach, develop into the perfect worm, from which seg- 
ments containing the eggs are again discharged. 

It would appear almost impossible for the embryo from 
these eggs, to ever enter the human stomach, but it is not 
difficult to understand that the fasces of the dog containing 
the ova, may enter a spring or stream, from which the 
minute embryo may be taken with the water, by either man 
or a lower animal; or, by attaching themselves to water- 
cresses, etc., they may be eaten with these by the same. 

Hydatid tumors of the liver, may vary, greatly, in size, 
according to their age. From an extremely minute cyst, they 
may acquire such a size as to fill and distend the abdominal 
cavity, crowding the several viscera from their position. 






OF THE LIVER; 185 

There may be one or several. They may be confined to the 
liver, or secondary cysts may appear in other organs. 

When opened, the interior is generally filled with numer- 
ous smaller cysts of various sizes, each filled with a gela- 
tinous fluid of varying degrees of density and color, and 
within which, by a careful microscopic examination, may be 
detected — many times, not always — numerous booklets, 
which have been detached from the minute heads. The 
walls of the parent cyst may become greatly thickened, or 
even calcified. The contents may degenerate into a puru- 
lent mass, with which may be mingled blood or bile. 

The development of these tumors is usually slow T , and 
unattended w 7 ith pain, or functional disturbance of the liver. 
After they have acquired a large size, they may induce 
peritonitis, resulting in extensive adhesions. 

Rupture of these hydatids sometimes take place, this 
accident being followed by death, or recovery, according to 
the point at which the rupture takes place. They may 
burst in the following directions : 

1. Through the diaphragm into the pleural cavity, or 
into the substance of the lunp-s. 

2. Rarely into the pericardium. 

3. Into the peritoneal cavity, resulting in acute peri- 
tonitis. 

4. Throuo-h the abdominal walls, when recovery is 
possible. 

5. Into the stomach or intestines ; this being; the most 
favorable point of rupture. In fifteen cases of rupture into 
the intestines, fourteen recovered. 

6. Into the biliary passages or large blood-vessels. 

Case. — Large Hydatid Tumor of the Liver — Death from Exhaustion. 

Mr. . of this city, aged 75 years, noticed some two years pre- 
vious to his death that his abdomen was enlarging. An examination 
disclosed the presence of a large tumor descending from the region of 



186 PATHOLOGICAL CONDITIONS. 

the liver. It was slightly fluctuating, and unattended with pain or 
soreness. He complained of nothing but weakness with vertigo. All 
the functions of the body were natural. 

A gradual increase of size took place, with occasional attacks of 
inflammation, until the abdomen acquired the dimensions of that of a 
woman at full term. The oppression now became so great, from the 
crowding of the lungs, that I decided to resort to paracentesis. Some 
two quarts of a thick, gelatinous fluid were drawn off from the tumor, 
with several quarts of ascitic fluid from the peritoneal cavity. The 
operation was followed by great relief. Rapidly refilling, the oppres- 
sion again became severe, and the operation was repeated a few months 
later with similar results. Death finally followed from exhaustion. 

The post-mortem revealed an immense tumor, filling the abdominal 
cavity with extensive, firm adhesions, and crowding the lungs into the 
upper part of the chest. The walls of the sac were thick and semi- 
cartilaginous, and the interior divided into numerous compartments by 
septa passing in various directions. These compartments were filled 
with a gelatinous fluid, in which were innumerable cysts of various 
sizes, each filled with a similar fluid as that with which they were 
surrounded. The microscope showed the presence of numerous cho- 
lesterine scales in this fluid. 

The weight of the entire tumor was over fifty pounds. A portion 
was preserved and deposited in the College Museum.* 

The following parasites are also sometimes found in the 
human liver, or its ducts : 

Distoma hepaticiim, or liver fluke. Common in the bile 
passages of lower animals, rare in that of man. It is flat, 
oval, from two to four lines long, and a-half to one line 
broad. Its presence in the hepatic ducts, may give rise to 
enlargement, some decree of obstruction, or calcification. 

Distoma lanceolatum. This parasite, something smaller 
than the above, is still more rare in the bile passages of 
man . 

Pentastoma denticulatum. This animal is found as a 
small cyst, with calcified walls, and containing fatty and 
calcareous matter, with the remains of the dead parasite. 



*See No. 1500, College Museum. 



OF THE LIVER. 187 

It is considered as the larval form of a worm sometimes 
found in the nasal cavity of the dog, and some other animals. 
The Ascaris lumbricoides may be found in some of the 
bile passages, it having entered by the opening of the 
common duct into the intestine. 



2. Affections of the Gall-bladder and Ducts. 

The o-all-bladder is sometimes wanting, this beino* the 
normal condition in the horse and some other animals,. 
When thus absent, the hepatic ducts are so increased in 
size, as to be able to contain the accumulating bile in the 
intervals of digestion. 






Inflammation of the gall-bladder and common duct, 
involving their mucous lining, is not uncommon. Such 
inflammation may be either catarrhal or suppurative. 

Catarrhal inflammation may result in thickening or 
calcification of the lining membrane of the ducts and blad- 
der, with the accumulation of such quantities of thick 
tenaceous mucus, as to become a source of impediment to 
the flow of the bile, and thus give rise to jaundice. Such 
inflammation becoming chronic in the common duct, may 
result in great dilatation of the ^all-bladder, from the accu- 
mulation of bile. 

In many cases, this form of inflammation would seem to 
have originated in the duodenum, reaching the biliary pass- 
ages by extension through the opening of the duct into the 
intestine. It may also result from the presence of calculi 
or parasites in the passages, or from inflammation of the 
liver. 

Suppurative inflammation may attend different forms of 
fevers, or result from the presence of calculi. The gall- 
bladder, with the bile ducts, in such cases, may be filled 



188 PATHOLOGICAL CONDITIONS. 

with a purulent fluid, or the same may be found infiltrated 
through their walls. 

Perforation of the walls of the gall-bladder may result 
from this form of inflammation, with escape of contents 
into the peritoneal cavity, inducing thus fatal peritonitis. 
Fistulous communication may also form between the bladder 
and colon, -duodenum or stomach, or through the abdominal 
walls, adhesions having first taken place between these parts. 

Dilatation, both of the bladder and ducts, may occur 
as a result of obstruction of the gall-ducts. That of the 
former may be very great, giving rise to a tumor that may 
be plainly felt through the abdominal walls. Dilatation of 
the ducts may involve either the common, or large hepatic 
ducts, or the smaller branches within the liver. Such 
dilatations may be sacculated in form, or general, involving 
the whole tube. 

Morbid Growths. 

Cancer of the walls of the gall-bladder is not unfrequent 
and may be either primary or secondary. The cavity of 
the bladder may in this way become obliterated, and the 
common duct obstructed, thus inducing jaundice. 

In a case examined for the Drs. Pettingill, the gall- 
bladder was as large as the fist, from scirrhus cancer ; its 
cavity obliterated ; adhered to the pylorus to which the 
disease had extended ; and the bile ducts greatly dilated 
and filled with a large quantity of puriform fluid. The 
patient had been for many months extremely jaundiced. 

Fibroid tumors are very rarely observed in connection 
with the gall-bladder. 

Tubercular deposits may be found beneath its peritoneal 



Biliary Calculi. The presence of biliary calculi, or gall- 



OP THE LIVER, 189 

stones in the gall-bladder, or some of the ducts, is a very 
eommon occurrence. These bodies are composed of the ele- 
ments of the bile, largely however of cholesterine, some- 
times in an almost pure state, in others, more or less mixed 
with inspissated bile. In many cases, a nucleus of nearly 
pure cholesterine will be surrounded by a deposit of biliary 
matter mixed also with scales of cholesterine. 

Cholesterine is a peculiar spermaceti, or fatty-like sub- 
stance, found not only in the bile, but also in the nervous 
tissues, insoluble in water, but soluble in aether or boiling 
alcohol. When found in a pure state, it is of a yellowish- 
white color, with the particles arranged in the form of shining 
thrombic scales. 

Gall-stones may occur of all sizes, from a pin's head to that 
of a hen's egg. When small, they are generally numerous ; 
in some instances fifty to one hundred being; found in the 
gall-bladder at one time. When several are present in the 
bladder, they will be more or less angular or polyhedral in 
form from contact and attrition with one another. Where 
there are but one or two, the size may be considerable, while 
the form will be rounded, oblong or pear-shaped, and more 
or less regular. 

These bodies, when first removed, are usually heavier than 
water, but, after being dried, become considerably lighter. 
They are inflammable, and may be reduced to almost pure 
charcoal by burning. After having being exposed to the air 
for some time, they are very liable to crumble more or less 
completely. 

Position. 1. Gall-stones may be confined to ilie gall- 
bladder. This is the position in which they are more fre- 
quently found. There is every reason to believe that they 
may remain there for a long time without giving rise to any 
uncomfortable symptoms. We frequently find them after 
death in the gall-bladder of persons who, during life, ex- 
hibited no symptons of their presence. They are liable, 



190 PATHOLOGICAL CONDITIONS. 

however, when present, and particularly if numerous or 
large, to give rise to a sense of weight and dragging in the 
part, and to occasional attacks of pain, derangement of the 
stomach and vomiting; and may also excite inflammation 
and ulceration of the walls of the bladder. 

The presence of gall-stones, when in large numbers, may 
frequently be detected through the abdominal walls, as a 
hard resisting tumor, which, by grasping, may be made to 
elicit a rattling sensation, like pebbles in a bag. 

2. Gall-stones may become impacted in the neck, or cystic 
duct of the gall-bladder. In this case, it is likely to give 
rise to an attack of biliary colic, with vomiting, etc. As 
long as it remains in this position there will be no jaundice. 
Their presence, however, may excite inflammation ; yet we 
sometimes, in post-mortem examinations, find the neck of 
the gall-bladder blocked up by a calculus, when no symp- 
toms of such an obstruction existed during life. 

3. Gall-stones may form in some of the branches of the 
hepatic ducts within the liver. This is not a common point 
for the formation of these bodies. They are sometimes 
found, however, in cases of obstruction of the ductus com- 
munis. The concretions may be small and rounded, or 
branching casts of the tubes, resembling pieces of coral. 

4. Gall-stones may be lodged in the ductus communis 
choledochus. This is one of the most common situations 
for these bodies, and they may reach the point, either from 
the gall-bladder, or from the ducts from the liver. While 
in this position, the calculus is likely to give rise to jaundice 
with paroxysms of severe pain, which will be repeated from 
time to time, until it passes into the intestines. 

Effects. As already intimated, gall-stones may remain 
for an indefinite period in the gall-bladder or ducts, without 
giving rise to any symptoms. In many instances, also, they 
may undoubtedly pass the ductus communis when small, 
and be discharged by the bowels, without the knowledge of 



OF THE LIVER. 191 

the patient. More frequently, however, the passage of these 
bodies is accompanied with paroxysms of severe pain, the 
location and character of which will usually serve to indi- 
cate the true cause. Where, however, the body is too large 
1<> pass, its presence in the gall-bladder or any of the gall- 
ducts, may excite inflammation and ulceration in those parts, 
and thus lead to perforation and discharge of contents into 
the peritoneal cavity. 

Case. — Rupture of the Gall-bladder, with discharge of contents into 
the peritoneal cavity, followed by peritonitis and death. 

Mr. De K. T , of this city, aged about 60, had suffered from 

several attacks of severe pain in the region of the gall-bladder, which 
I had diagnosed as biliary colic, induced by the presence of a calculus. 
One morning in June, 1863, while working in his garden, he felt a 
sensation of something giving away in his side, which was immediately 
followed by an attack of severe pain. A chill and fever soon succeeded ; 
and, in twenty-four hours, a violent peritonitis set in, resulting in 
death in four days. 

Autopsy, thirty-six hours after death. Upon opening the cavity of 
the abdomen, the peritoneal membrane was found intensely inflamed 
at all points, and containing nearly a quart of greenish sero-purulent 
fluid. Slight plastic adhesions were found at various points, uniting 
the intestines to the abdominal walls, while old, firm and extensive 
adhesions were found between the same and the liver and gall- 
bladder. There were evidences that the latter had been largely dis- 
tended, yet, through a distinct opening, the contents had escaped into 
the peritoneal cavity, leaving behind a single calculus of a regular 
oval form, and one inch of its long diameter.* 

From the appearance of the part, it would seem that the calculus 
had excited inflammation and ulceration in the walls of the gall- 
bladder, destroying the latter so completely, that the fluid contents 
were kept from escaping into the abdominal cavity, only by the ad- 
hesions that had formed, and that these had been probably torn away 
by the exercise of digging with the spade. 

In many cases, the adhesions which are induced by the 
* Specimen No. 1329, College Museum. 



192 PATHOLOGICAL CONDITIONS. 

inflammation, will secure a more fortunate result, favoring 
the working of the calculus, by the ulcerative process, either 
into the duodenum or colon, and thus, in most cases, securing 
its passage per anum. In such instances, should an oppor- 
tunity he had of examining the parts after death, traces will 
be found remaining, sufficient to indicate the point at which 
the escape into the bowel was effected. 

In some rare instances, gall-stones have been vomited 
from the stomach. While it might be possible for such 
bodies to be carried from the duodenum into the stomach by 
a reversed peristaltic action, it is more probable that, in such 
cases, the calculus has found its way into the stomach by 
a direct fistulous communication with the gall-bladder. 

Fistulous communications of a permanent character are 
sometimes left, after an ulcerative discharge of a galhstone 
into some portion of the intestinal canal. 

Gall-stones, after entering the intestinal canal, may 
become impacted, thus producing intestinal obstruction. 
Many fatal cases of this character have been reported. 
An interesting case of intestinal obstruction from this 
cause, was reported by Dr. Frieze, of Harrisburg, at the 
meeting of the American Institute of Homoeopathy, in 
Philadelphia, in June, 1871. A lady sixty-five years of 
age, had been suffering severe pain in the bowels for over 
a week, with symptoms of obstruction, when, after a perse- 
vering use of injections, she passed a calculus of a cylindrical 
form, one and three-quarter inches in length, and four and 
one-half inches in circumference, and weighing four hundred 
and thirty-seven and one-half grains.* 

Gall-stones have, in a number of cases, been discharged 
upon the surface of the body, while in some rarer instances, 
by the ulcerative process they have worked into the ureter, 
and even into the vena cava and portal vein. 

* See No. 1336J, College Museum. 



OF THE KIDNEYS. 193 

CHAPTER II. 
THE URINARY APPARATUS. 

Section I. THE KIDNEYS. 

[Notice : — Absence of either kidney, or other abnormalities. Of 
each kidney, note 1. Form, size, weight, wounds, etc. 2. Capsule — 
thickness ; transparency ; facility of removal. 3. Surface of kidney 
after removal of capsule — color; smooth or lobulated, size of lobules ; 
puckerings ; granulations; cysts, etc, 4. Substance of kidney — con- 
sistence: flaccidity, etc.; fracture, granular or not? wounds, rupture. 
5. Cat surface — color of pyramidal and cortical portions; proportion 
of each; amount of blood exuding from ; thickness of cortical portion ; 
color; Malpighian corpuscles; their degree of visibility, color, etc.; 
appearance of strias in pyramidal portion, color, etc. 6. Abnormal 
growths and deposits — cysts; fibrinous masses; tubercle ; cancer; chalky 
masses; abscesses, etc. 7. Pelvis of kidney — peculiarity of form ; con- 
tents; fluid, quantity, quality, purulent, etc. Calculi — their size, 
position, etc. Walls of pelvis — their thickness; transparency; fistulous 
openings ; wounds, etc. 8. Ureters — size, contents, etc. 9. Microscopic 
examination — make section with Valentine knife, from convex border 
through cortical portion, and from base to apex of cone, parallel 
with tubules; place on slide and examine with varying powers, from 
100 to 500 diameters. Note condition of tubules — contents; blood, oily 
particles, fibrinous, waxy, epithelial or other casts ; or denuded of 
epithelium and empty. Malpighian tufts — gorged, ruptured, filled 
with granular or oily matter, or obliterated. Are crystals of any 
kind present, as uric acid, oxalate of lime, etc., minute cysts, purulent 
infiltration, tubercular, cancerous or other deposits?] 

In the normal state, in the adult, each kidney will be 
found to be about four inches in length, two inches in 
breadth, and one inch in thickness, of a firm consistency, 
and of a deep, red color. The weight of the kidney varies 
from four ounces to six ounces, being somewhat lighter in 
the female than in the male. The left kidney is generally 
somewhat longer, thinner and heavier than the right. The 
fibrous capsule in which each kidney is enveloped is thin, 
smooth, and in a state of health is easily removed from the 
surface of the gland. 

13 



194 PATHOLOGICAL CONDITIONS. 

Congenital Anomalies. Although the absence of 
both kidneys is of rare occurrence, it is not uncommon 
to find only one. This may occupy its usual position, and 
differ from the natural kidney only in being larger — the 
unsymmetrical kidney of Rokitansky. In other cases, we 
find a more or less complete fusion of the two organs 
together — the solitary kidney.* Either the lower parts of 
each are connected by a band of renal substance passing across 
the vetebfal column, constituting the horse-shoe kidney ; or 
there is only a single disk-like gland, lying in the median 
line, and situated much lower down, even as far as the 
concavity of the sacrum. 

Congestion. This, and its consequences, are the main 
features of hypersemia of the kidneys, which is of frequent 
occurrence. This condition is almost always the result of 
some prior general affection, such as the scarlatinal poison, 
the suppression of perspiration, or obstructive diseases of 
the heart. 

In a simple congestion, with perfect integrity of the renal 
tissue, we find the kidney enlarged, and its weight often 
doubled ; of a dark, red color, and dripping with blood when 
cut into. The cortical substance is somewhat softened, of a 
dark, red color, presenting in many cases small dark, red 
spots, the result of hsemorrhagic effusion into and between 
the tubercles. The Malpighian tufts are distinctly visible on 
the cut surface, as minute, reddish, semi-transparent grains. 
In the medullary cones, the congested vessels form long 
dark-red streaks. If the congestions have occurred in an 
otherwise healthy kidney, the capsule can be readily peeled 
off. 

A microscopic examination shows the Malpighian and 
other capillaries loaded with blood, extravasation sometimes 

* See No. 1259, College Museum. 



OF THE KIDNEYS. 195 

taking place into the capsule of the latter, and often into 
the channel of the fibres. 

In extreme cases of hyperemia and congestion, a fibrinous 
exudation takes place, which will be found coagulated in the 
tubes, forming casts of their interior, and consisting of a 
granular or homogeneous material, entangling blood-globules, 
and often some particles of detached epithelium. 

Haemorrhage. As a result of acute congestion, or 
from injury from falls, blows, or wounds of the kidneys, 
blood may be effused, either beneath its capsule, or within. 
the sinus, constituting haemorrhage of the kidney. 

Nephritis. This differs in no material respect fronr 
common inflammation of other parts, and like it, often 
passes into suppuration. 

Its most common causes are :— Excess in the use of 
irritating and alcoholic drinks ; abuse of diuretics ; blows 
or falls on the loins; the presence of renal calculi; and,, 
according to some authors, a peculiar morbid state of the 
blood, such as gives rise to carbuncles. 

This disease can be distinguished from the inflammatory 
form of Bright's Disease, during life, by its generally affect- 
ing only one kidney, by the much greater pain and tender- 
ness in the lumbar region, by the retracting of the testicles, 
and the higher degrees of febrile excitement. Then, too, 
the deeply-colored urine which is voided, contains little or 
no albumen. 

In a case of nephritis, unattended with the formation of 
pus, a post-mortem would probably fail to distinguish it 
from the condition of congestion just considered. Where 
suppuration was about taking place, the microscope shows- 
the cortical tubes so distended and crowded together by 
infarcted epithelium, as to be scarcely distinguishable ; in 
some parts the basement membrane gone, and their contents- 



196 PATHOLOGICAL CONDITIONS. 

a uniform mass of nuclei and granular matter. The medul- 
lary tubes are also infarcted and opaque. 

Pyelitis. Inflammation of the walls of the sinus of the 
kidney, is thus designated. It may exist alone, or in com- 
pany with inflammation of the kidney, constituting Pyelo- 
nephritis: It appears to originate, in many cases at least, 
secondarily to an attack of cystitis, and would seem metas- 
tatic in its nature, the ureter connecting the two inflamed 
organs, escaping the disease. It is a very serious, and often 
rapidly fatal disease. 

Where the inflammation extends to the kidney tissue, 
suppuration is likely to follow, resulting thus in the forma- 
tion of an abscess. 



Abscesses. Renal abscesses are found bordered by a 
red injected halo, which gives rise to a friable product, thus 
leading to an extension of the abscess. The mucous mem- 
brane of the calices and the pelvis, especially when a cal- 
culus is present, is softened and inflamed, and secretes a 
purulent fluid. 

The process of suppuration may continue until the whole 
organ is converted into a pouch of pus. Then, or even 
before the organ is quite destroyed, the abscess may make 
its way by the usual process of absorption, and discharge 
its contents into the calices, to be carried off by the urinary 
passages ; into the ascending or descending colon, or the 
duodenum, to be passed with the faecal evacuations ; or, 
after perforating the diaphragm, into the bronchi, whence 
they are removed by coughing; or through the lumbar 
muscles ; or it may burst into the peritoneal cavity and 
cause rapid death. 

This disease rarely attacks more than one kidney, and 
the other healthy kidney generally enlarges and becomes 
capable of performing a double amount of work. 



OF THE KIDNEYS. 197 

It is well to remember, that a mass of softened fibrinous 
exudation, bordered by a red halo, may sometimes so far 
simulate an abscess, that only the microscope can dis- 
tinguish the one from the other. 

Inflammation of the Capsule may take place and 
cause fibroid thickening, more or less induration, atrophy, 
and obliteration of the or«;an. The cortical substance gen- 
erally suffers most, and the surface is sometimes overspread 
with purulent matter, while the tissue itself becomes 
sloughy or gangrenous, or is only congested and softened. 

Morbus Brightii. BrigMs Disease. Degenerative 
disease of the kidneys. Desquamative and un-desquama- 
tive nephritis. 

In view of the impossibility of accurately defining the 
term BrigMs Disease, we will describe it in general 
as including those diseases of the kidneys which, in some 
stage or other of their course, are accompanied by albu- 
minuria, or dropsy, or both. And as it would be foreign 
to the object of this work, to enter into an examination 
of the respective merits of the theories, in reference to 
the nature and course of this disease, we will adopt that 
classification which seems best adapted to our purpose, and 
proceed to consider the morbid anatomy of Bright's Disease 
in its various forms and stages as first suggested by Vir- 
chow in his Cellular Pathology, and adopted and developed 
by Stewart.* 

He distinguishes three forms — (1) the inflammatory, (2) 
the waxy, (3) the cirrhotic or contracting ; the first origi- 
nating in the tubules, the second in the vessels, and the 
third in the connective tissue of the organ. 

1. The Inflammatory Form. This has three stages : that 

* Bright's Disease, by T. Grainger Stewart. 



198 PATHOLOGICAL CONDITIONS. 

of inflammation, that of fatty transformation, and that of 
atrophy. The disease may prove fatal at any stage of its 
course. In the first stage, an exudation is poured out, and 
a destruction of the epithelium takes place. This exudation, 
affecting a large number of tubules, leads to enlargement of 
the organ, and also to fatty degeneration of the epithelium ; 
its absorption or removal, leads to ultimate atrophy. There 
is also a fatty degeneration, to which we will refer later, 
which is unattended either with albuminuria or with dropsy, 
and which does not, therefore, belong to this category. 

In this stage of inflammation, the organ is of the natural 
size, or slightly enlarged; its capsule is unaltered, and can be 
peeled off readily; its surface is smooth, more or less con- 
gested, often pink, sometimes of a dark purplish color, some- 
times mottled, pale and purple. On section, the cortical 
substance is found relatively enlarged, and often congested. 
The Malpighian bodies stand out prominently from the sur- 
rounding tissues, the congested vessels, separated by a 
varying amount of white (somewhat opaque) deposit, com- 
posed of the altered tubules. The vascular spaces between 
the cones and the cortical substance are uniformly distended 
with blood. The cones are usually redder than the cortical 
substances, and from the engorgement of their vessels and 
the altered condition of their tubules, they present a series 
of alternating red and white lines, converging to the apex of 
the cone, at which point the white distinctly predominates. 
The pelvis of the kidney is natural. 

Examination with the higher powers of the microscope 
shows the Malpighian bodies dense and granular. The 
tubules are more bulky than natural, and their epithelium 
is swollen, granular and dense, wdiile within them is fre- 
quently seen a transparent homogeneous exuded material, 
binding into one mass, the epithelium of the tubules. Blood 
corpuscles are frequently found incorporated in this exuded 
material. 



OF TPIE KIDNEYS. 199 

In the stage of fatty transformation, the organ is enlarged; 
its capsule natural; its surface smooth or slightly tabulated. 
It is pale and fatty in color, and on its surface stellate 
vessels are frequently seen. On section, the cortical sub- 
stance is pale, of a yellowish- white color, and increased in 
volume, while the cones are pink, and of natural color and 
size. The Malpighian bodies do not project prominently as 
in the first stage. 

Under the microscope we find the tubules to be irregularly 
distended with fatty granules, contained for the most part 
within the walls of the epithelial cells, which again are 
imbedded in a material that blocks up the tubules. In the 
Malpighian bodies, oil globules and fatty cells are of frequent 
occurrence, but the capillary tuft is natural. 

In the last stage of this form, that of atrophy, both the 
bulk and weight of the organ are diminished, its capsule 
although natural, is less easily torn off than in health, and 
on its removal the surface of the gland is found to be 
uneven, with numerous depressions and elevations. The 
color is, as in the second stas^e, mottled. On section we 
find that, while the cones have remained nearly of their 
natural size, the cortical substance is small and atrophied, 
and that which intervenes between the cones is greatly 
diminished. In the cortical substance, the Malpighian 
bodies are not prominent, while the vessels, and especially 
the arteries, are thicker and more prominent. 

The pathological distinction between this stage of the 
inflammatory form, and the cirrhotic or contracting kidney, 
depends mainly upon the condition of the tubules and the 
relative amount of connective tissue. When the atrophy is 
a consequence of inflammation, many of the tubules -show 
evidences of inflammatory action, being blocked up with 
exudation and epithelium in process of fatty degeneration, 
while in the cirrhotic there is little or none of this. Again, 
in the cirrhotic the fibrous stroma is very greatly increased, 



200 PATHOLOGICAL CONDITIONS. 

which is not the case in the inflammatory form. In the 
latter, too, the capsule is more easily stripped off, and the 
occurrence of cysts is less frequent than in the former. 

The form of Bright's Disease, of which we are treating, is 
often complicated with hypertrophy of the heart, affections 
of the lungs and bronchi, inflammation of serous membranes, 
derangements of the alimentary tract, diseases of the brain, 
affections of the eye, liver and spleen. 

2. The Waxy or Amyloid Form. This also has three 
stages : that of simple degeneration of the vessels ; that in 
which a secondary alteration of the tubules is suspended; 
and that of atrophy. An increased secretion of urine char- 
acterizes this form from its earliest stages. In all stages 
the vessels present to the naked eye more or less distinctly 
the appearance of boiled starch or sago, while a little of the 
liquor iodi poured over the surface, produces everywhere a 
yellowish color, but the degenerated parts assume a reddish- 
brown, mahogany-red, or orange-red hue, and stand out very 
conspicuously. 

In the first stage, the organs are of normal size, weight 
and color, the latter being however, in some cases, a little 
paler than usual. Their capsule is easily stripped off, and 
their surface is smooth. The waxy degeneration begins in 
the capillary tufts of the Malpighian bodies, and in the 
transverse fibres of the middle coat of the small arteries. 
On these there are thickenings here and there, presenting 
the same sago-like translucency as is seen in the tufts. 

In the second stage, the kidneys are increased in bulk and 
weight ; the capsule is easily stripped off, and the surface 
smooth and pale. The cortex is thick and white, and 
presents much the appearance of white beeswax. Under 
the microscope, we see the Malpighian bodies and arteries 
degenerated as just described, and in addition many of the 
tubules full of matter, not dense and opaque as in the 
inflammatory form, but tolerably transparent, consisting of 



OF THE KIDNEYS. 201 

hyaline tube casts. Their epithelium is swollen, and their 
basement membrane may also be waxy. It is to this form 
of disease that the term " waxy kidney" is most applicable. 

In the third stage, that of atrophy, the organ is reduced 
in bulk, from about the natural size to a fourth or even less. 
Its weight is also diminished. The capsule may be torn off 
without much difficulty. The surface is rough, granular, 
and of a pale, waxy color. On section the cortical substance 
is found much diminished, while the cones are nearly natural. 
The Malpighian bodies are large and closely grouped together; 
the smaller arteries dilated and their walls thickened. A 
few tubules remain distended, but most are collapsed, and 
are represented only by fibrous tissues. 

3. The Cirrhotic or Contracting Form. This consists of 
an hypertrophy of the connective tissue of the organ, and a 
consequent atrophy of all the other structures. It has been 
termed also "gouty kidney," " intertubular or interstitial 
nephritis," and " granular kidney." 

In the commencement of the process there is but little 
diminution in the size of the organ, but the capsule is thick- 
ened and more adherent than natural, and the surface is 
rough and granular. The color is pale or reddish. On sec- 
tion, the cortical substance is found relatively diminished, the 
diminution being most marked towards the surface. The 
arteries are prominent, their walls thickened and their cavi- 
ties often dilated. Even to the naked eye, and to the touch, 
the increased density and fibrousness of structure are evident. 
On the surface, and in the substance, cysts are frequently seen. 
Some are produced by dilatation of the Malpighian capsules, 
some by dilatation of the tubes, and others from morbid growth 
of epithelial elements. The tubes are compressed and atro- 
phied by the new fibrous tissue. They contain little of the 
opaque matter found in inflammatory cases, but translucent 
hyaline matter is common. All these characteristics become 
more marked as the disease progresses. In the more ad- 



202 PATHOLOGICAL CONDITIONS. 

vanced stages, both the kidneys are much reduced in size, 
but one may be more atrophied than the other. Throughout 
the whole course of the disease the cones are but little 
affected. 

In gouty cases a deposit of chalk-like substance is occa- 
sionally found, composed of needle-like crystals of urate of 
soda; situated in the stroma of the organ, as well as in the 
tubules. 

In distinguishing a cirrhotic kidney from one in the third 
stage of the inflammatory or of the waxy disease, besides 
the characteristic iodine test in the one case, the following 
points of comparison will be useful: — In the cirrhotic, the 
capsule is more thickened and more adherent than in the 
other two forms. In the cirrhotic, the surface is very 
uneven, frequently studded with cysts, and presents little or 
no sebaceous-looking material; in the inflammatory and the 
waxy, the surface is less uneven, cysts are much less 
common, and in both, particularly the inflammatory, seba- 
ceous-looking material is very abundant. In the cirrhotic, 
the stroma is greatly increased, especially towards the 
surface; in the inflammatory and waxy, the stroma, although 
increased relatively to the other tissues, is not absolutely 
above the normal amount. 

It must also be borne in mind, that both the waxy and 
contracting forms may be secondarily affected with the 
inflammatory disease. 

Simple Fatty Degeneration of the Kidneys. We 

occasionally find, along with fatty degeneration of the liver 
and of the muscular substance of the heart, a fatty degenera- 
tion of the kidney, without any trace of inflammation. The 
kidneys are of about the normal size ; the surface smooth, 
and the capsule not adherent. The organ is more soft and 
flexible than natural, and the surface is pale, and mottled 
with sebaceous-looking deposits. On section, we find the 



OF THE KIDNEYS. 203 

abundant deposition of sebaceous-looking material to be 
mainly in the tubules of the cortical substance, but also to 
be found in those of the cones. The microscope shows that 
the deposit is not in the free cavity of the tubes, but within 
the epithelial cells. 

We may have the simple fatty degeneration in connection 
with exhausting disease, old age, or with excess of fatty food. 

The adipose tissue in which the kidney lies embedded, 
may increase to such a degree as to penetrate by the hilus 
into the substance of the organ, impede its nutrition, and 
induce a kind of atrophy. Rokitansky states that, in the 
highest degree of this change, the kidney presents the 
appearance of a mere mass of fat, without the slightest trace 
of renal organization ; the urinary passages at the same 
time being atrophied and obliterated. 

Dislocated Kidney. As a result of over-exertion, 
tight lacing, or perhaps pregnancy, the kidney sometimes 
becomes detached from its connections to the surrounding 
structures, permitting of a change of position, and con- 
stituting what is known as movable or dislocated kidney. 
The right kidney is said to be more frequently affected 
in this manner, and the condition is more common with 
females than males. 

Morbid Growths. 

Tubercular Disease, though not of frequent occur- 
rence, does sometimes occur in the kidneys. In most cases 
we find a deposit of tubercle in other organs, especially in 
the lungs, and often in various parts of the genito-urinary 
apparatus. 

This disease is most liable to occur in the middle period of 
life. It is found sometimes in the miliary form, sometimes 
in larger masses. 



204 PATHOLOGICAL CONDITIONS. 

In a very decided tubercular dyscrasia, we find associated 
with the miliary granulations a considerable amount of 
hyperemia of the organ ; but where the deposit is more 
chronic, the surrounding tissue is quite pale. The large 
masses are remarkably bloodless. When the tubercular 
deposits extend to the renal tissue from the mucous mem- 
brane of the calices and the pelvis, these cavities become 
remarkably enlarged, and the whole organ is increased in 
size, and appears rather pale. The epithelial lining of the 
tubes is more or less opaque and granular, or of an oily aspect. 
By the softening and breaking down of the tuberculous 
deposits, large cavities are formed, containing a mixture of 
tuberculous detritus and pus. Fibrinous casts are some- 
times found in great numbers in the tubes. 

Cancer. Secondary, is of more frequent occurrence than 
primary cancer. The scirrhus and colloid varieties are 
rarely, if ever, found. Encephaloid growths, especially in 
children, attain in the kidneys an enormous size. 

Cancer of the liver and right kidney, or of the adjacent 
parts of the stomach, or descending colon and left kidney, 
frequently coexist according to the observations of M. Rayer 
and Dr. Walshe. The period of life between fifty and 
seventy is most liable to cancer of the kidneys. 

The natural character of the urine excreted by cancerous 
kidneys is seldom changed until the encephaloid growth 
softens and breaks down, when blood, puriform matter and 
detritus may appear. 

Cystic Tumors, supposed to originate from a dilatation 
of the Malpighian capsules, are sometimes found. The cysts 
vary in size from a pin's head to a small bird's egg. They 
may be few or many in number, and are filled either with a 
clear watery fluid, or with a gelatinous or pigmentary sub- 
stance. The walls of the cysts are thin and smooth, partly 



OF THE KIDNEYS. 205 

divided into compartments by imperfect septa. They are 
confined to the cortical portion of the gland, and may be 
imbedded in that substance, or project from the surface. 
The kidney may be unchanged in size, or considerably 
enlarged. The clinical symptoms of these cysts are very 
obscure, and of the cause of their formation, little is known.* 

Cysts of a congenital origin, are sometimes found in the 
kidney at birth. They may be of great size, and vast 
number, and appear to result from a dilatation of the 
uriniferous tubes, and Malpighian capsules. 

Fibroid and Adenoid tumors of small size are rarely 
found in the kidneys; the former within the tubular, the 
latter within the cortical portions. 

Parasites. 

Entozoa are occasionally found within the kidneys, 
among which may be mentioned the hydatid, or larval 
form of the Taenia echinococus. 

Cysticercus celhdosce. The larval form of the Taenia solium. 

Eustrongylus gig as. A small cylindrical worm, with the 
body tinged with red. Male — ten to fourteen inches long, 
three lines wide. Female — three feet lono-, six lines wide. 

Pentastoma denticulatum. Supposed to be the larval form 
of a worm found in the nasal cavities of some animals, and 
consisting of a small sac, with calcified walls. 



The Ureters. 

As a congenital defect, we find the ureter terminating in a 
cul-de-sac, either in the vicinity of the kidney, or of the 
bladder. Sometimes they are double or even triple, but 
they generally unite before their vesical termination. 

* See No. 1507, College Museum. 



206 PATHOLOGICAL CONDITIONS. 

Dilatation. When the opening into or from the bladder 
has, from some cause or other, become greatly narrowed or 
obliterated, the obstacle to the passage of the urine causes a 
dilatation of the ureters* The sinus and calices at the 
same time, dilate at the expense of the renal tissue, so 
that we frequently find but a thin layer of cortical substance 
compressed against the investing capsule, and the kidney 
converted into a number of pouches, separated by the re- 
mains of the medullary cones. The surface of the kidney 
is markedly lobulated. 

The distention of the ureters may reach such a degree, 
that they resemble a portion of small intestines, their walls 
being at the same time somewhat thickened. 

From an increase in length sometimes met with, the 
ureters no longer lie straight, but are thrown into coils or 
flexures. With dilatation of the ureters, we not unfrequently 
find coexisting a state of 

Inflammation. The mucous membrane is then found 
swollen and injected, of a villous aspect, and covered with a 
muco-purulent fluid. Sloughing may ensue with conse- 
quent perforation of the Ureters and infiltration of the urine 
into the adjacent tissues, producing an extension of the 
sloughing process or circumscribed abscesses. The inflam- 
mation rarely exists as a primary disease; its most frequent 
causes, are the irritation from calculi, or the extension of 
vesical disease. It may extend to the sinus of the kidney, 
constituting pyelitis. 

Morbid Growths, 

Cancer of the urinary passages but seldom occurs, and 
only when found elsewhere at the same time. 

* Specimen No. 1260, College Museum, 



OF THE KIDNEYS, 207 

Tubercles may occur in the ureters, even when the 
kidneys arc healthy, but most frequently where they are 
involved at the same time. These usually coexist with 
tuberculosis of some important organ. "The deposit takes 
place in the submucous tissue, and forms, when its progress 
is chronic, gray granulations, which become yellow, soften, 
and give rise to small circular ulcers. When the disease is 
more acute, larger patches of deposit are formed, or the 
mucous membrane becomes infiltrated throughout with the 
tubercular product of inflammation, which is at once detached 
as a cheesy, purulent mass." 

Cysts, containing a glutinous or hard matter, about the 
size of millet-seeds or peas, are occasionally found developed 
under the mucous membrane of the urinary passages. 



The Suprarenal Capsules, 

These bodies are sometimes entirely absent. Where one 
of the kidneys is absent or displaced, the capsule may still 
be found in its normal position. 

Inflammation and Degeneration. Inflammation of 
the bodies, either acute or chronic, appears to result in the 
following changes: 

First, the organs become slightly enlarged and infiltrated 
with a semi-translucent material, of a grayish color, soft, 
homogeneous, or slightly fibrillatecl, or containing a few im- 
perfect cells. The substance resembles what is often seen 
in scrofulous disease of the lymphatic glands. 

At a later period, this substance gradually changes into a 
soft, putty-like substance, or into chalky concretions scat- 
tered through the body. The whole substance of the organ 



208 PATHOLOGICAL CONDITIONS. 

may thus be destroyed. It may, at the same time, be 
found more closely adherent to the surrounding organs. 

Dr. Addison has associated with these changes in the 
suprarenal capsules, a peculiar bronzed condition of the shin 
sometimes seen, and named from him "Addison's Disease." 

Haemorrhage occasionally occurs within the substance 
of the capsule, forming a kind of cyst filled with blood. It 
is more frequent with young children, but is sometimes seen 
in adults. 

Morbid Growths. 

Cancer. Primary cancer of these bodies is rare; the 
secondary form may appear in connection with the same 
disease in the kidneys, stomach or liver. 

Tubercles of the miliary form are rarely seen. 

Cysts, both single and multiple, and with varying con- 
tents, may be found, generally connected with the enclosing 
membrane. 



Section II. THE URINARY BLADDER. 

[Notice : 1. External Characters — malformations : adhesions ; size ; 
Wounds, etc. 2. Walls — their thickness; condition of several coats ; 
morbid growths, cancer, tumors, tubercles, perforations; sinuses; rup- 
ture; wounds. 3. Contents — urine, its quantity and characters; blood, 
its amount and source; pus; calculi, number, size, position, etc.] 

Malformations. Among the most common of these, 
may be mentioned extroversion, where there is an absence of 
the anterior walls of the bladder, with a deficiency in the 
corresponding portion of the abdominal parietes. From the 
pressure of the abdominal viscera, the posterior walls of the 
bladder will be crowded forward, and protrude as a rounded 
tumor, covered by a vascular mucous membrane, while near 
the lower portion may be seen the orifices of the ureters, 



OF THE BLADDER. 209 

through which the urine will be more or less constantly 
flowing. 

Malformations of the external organs of generation, are 
liable to accompany those of the bladder. 

The Urachus sometimes fails to close before birth, leaving 
thus an open passage from the fundus of the bladder to the 
umbilicus, through which the urine may be noticed flowing 
after division of the cord. 

Dilatation. This is of not unfrequent occurrence, and 
is the result either of a paralysis of the muscular coat, or 
of some obstacle to the outflow of the urine. The dilatation 
may be uniform, or we may find diverticula, formed by a 
protrusion of the mucous membrane between the fasciculi 
of muscular fibres. Such partial distensions occur most fre- 
quently in the lateral portions, the posterior surface, or' the 
neighborhood of the fundus, and as we should be led to 
expect from the manner of their formation, are generally 
destitute of a muscular tunic, or have but a few scattered 
fibres. Calculi are sometimes found in these pouches after 
death, the presence of which had escaped notice during life 
from their concealed position. 

Hypertrophy of the muscular coat of the bladder, will 
generally be found attending cases of obstruction to the 
escape of the urine, either from an enlarged prostate, 
stricture of the urethra, or from the presence of a calculus. 
The muscular coat in these cases is greatly thickened, the 
interlacing bundles of fibres appearing with great distinct- 
ness upon the inner surface. 

As a result of this condition, w T e usually find the bladder 
greatly contracted, its capacity in some cases being reduced 
to one or two ounces. Inflammation of the mucous coat, 
with dilatation of the ureters, will also generally attend 
hypertrophy of the muscular walls. 

14 



210 PATHOLOGICAL CONDITIONS. 

Contraction of the bladder is met with, as the result 
either of irritation of the mucous membrane, or hypertrophy 
of the muscular coat. 

Inflammation of the bladder is generally seen in its 
chronic form. 

The appearances in acute cystitis are " strong vascular 
injection of the mucous lining, with brownish patches in the 
vicinity of the neck and fundus ; more or less thickening of 
the membrane, with exudation of fibrin or pus on the sur- 
face, or foci of the latter in its substance. The mucous tissue 
may be ulcerated at several points, softened or affected 
by commencing gangrene. Abscesses may form in the sub- 
stance of the parietes, and open either into the cavity of 
the bladder, or upon its external surface. Sometimes the 
mucous membrane is almost completely destroyed, a few 
shreds or filaments being the only traces remaining, while 
the muscular tunic is left as if cleanly dissected. This is 
probably the result of phagedenic ulceration." The inflam- 
mation may spread from the mucous membrane to the 
muscular coat, but it very rarely reaches the peritoneal 
covering. In some cases it extends back along the ureters, 
and even to the kidneys. The morbid action is not often of 
idiopathic origin, it is more frequently due to the extension 
of an attack of gonorrhoea, to disease of the prostate, to 
traumatic causes, to protracted retention of urine, or to 
the irritation produced by medicines or stimulating drinks. 
It is sometimes owing to the constitutional poison of rheu- 
matism or gout. It is met with oftener in men than 
women, and in adults than in children. 

Chronic cystitis, called also catarrh of the bladder, is very 
common in advanced age. The morbid process is excited by 
some obstacle to the emission of the urine, either paralysis 
of the viscus, or a stricture, or by presence of a stone in the 
bladder, or by enlargement of the prostate gland. It may 



OF THE BLADDER. 21 

also result from successive attacks of the acute form, or from 
extension of urethral inflammation. 

Various degrees of vascular injection are presented, with 
dark-reddish, slate-colored or bluish-black discoloration ? 
more or less thickened induration of the parietes, which 
assume an homogeneous, lardaceous appearance. An acute 
attack may supervene upon a state of chronic inflammation, 
leading to ulceration, suppuration, perforation and extrava- 
sation of urine, as in the case of primary acute cystitis. 

Chronic or sub-acute inflammation is often attendant upon 
paraplegia, and proves the immediate cause of death. 

Morbid Growths. 

Cancer as a primary disease, is but rarely met with. 
Encephaloid, forming nodulated prominences or cauliflower- 
like excrescences, is the form which vesical cancer usually 
assumes. They are developed in the submucous tissue, but 
as they grow, the mucous membrane is also destroyed, and 
either an ulcer is produced or a soft luxuriant fungous mass. 

Tubercle in the form of separate granulations are some- 
times met with about the fundus and neck of the bladder 
in the male, and usually are accompanied with similar 
deposits in the testes, prostate, kidneys, etc. They are 
surrounded by more or less hyperemia, and by softening 
give rise to circular ulcers of the mucous membrane covering 
them.* 

Tumors. Polypoid growths, both of a fibrous and 
adenoid character, may be found in the neck of the bladder, 
both in children and adults. They vary in size from that 
of a pea to a cherry. 

* See No. 1261, College Museum. 



212 PATHOLOGICAL CONDITIONS. 

Cystic tumors of small size are sometimes found within 
the mucous membrane. 



Parasites. 

The Sarcina ventriculus, a vegetable parasite, is some- 
times found in the bladder, in cases of chronic cystitis. 

Of animal parasites, the Eustrongylus, Echinococus, and 
Ascarides, have found their way into this organ from other 
parts. 

Of the Urethra. 

Malformations. As congenital malformation, we need 
mention only Episp>adias, fissure on the upper, and Hypos- 
padias, on the lower surface, from arrest of development, 
and complete closure of the opening, Atresia urethrce. 

Inflammation of the urethra, of the catarrhal kind, the 
so-called gonorrhoea, commencing at the anterior extremity, 
may, in severe cases, extend backwards, even into the bladder. 
The lining membrane becomes swollen, injected, and covered 
with mucus or muco-purulent secretion, at first thin, then 
thicker, and then, as the inflammation subsides, thin and pale 
again. When a chancre coexists with gonorrhoea, " the dis- 
charge has usually a grayish or reddish tint, or sanious 
aspect." From an extension of the inflammation deeper 
into the fibrous structure of the corpus spungiosum, results, 
sometimes, an exudation of fibrin in the venous cells, sup- 
puration and abscess. Cowper's gland, the prostate, the 
vesiculse seminales, and the testicles, may also be affected 
by an extension of the inflammation along the continuous 
mucous lining. 

The contact of unhealthy vaginal secretions, whether 
specific or not, is the most frequent cause of urethritis. 



OF THE URETHRA. 213 

Dilatation and Contraction. Dilatation is most fre- 
quently the consequence of obstruction to the flow of urine. 
It occurs generally in the membranous portion, which is ex- 
panded into a pouch, occasionally as large as a small orange. 
The mucous lining of these pouches appears "injected and 
thickened, presenting fungous vegetations, and occasionally 
coated with lymph." 

Contraction may result from inflammation of the mucous 
membrane, and finally end in stricture. 

Stricture is a very frequent result of inflammation of 
the urethra. It usually is found in the anterior part of the 
membranous portion. Contusions and wounds also, often 
produce stricture. 

The simplest form of stricture is, where the canal is 
partially closed by a fold of membrane passing across it, 
leaving either a crescentric, or annular opening. In the 
most common kind of stricture the urethra is narrowed in a 
much greater extent of its course, sometimes for an inch, or 
more. When the obstruction occasioned by a stricture is very 
great, the urethra behind is dilated, often inflamed and 
sometimes ulcerated, so as to give rise to urinary fistula or 
effusion of urine. 

Rupture of the urethra may result from severe contu- 
sions, or fracture of the bones of the pelvis, and being fol- 
lowed by extravasation of blood and urine, inflammation, 
suppuration or gangrene may supervene, or fistulous open- 
ings may be thus established. 

Morbid Growths. 

Warty groivths sometimes appear within the urethra near 
the meatus. They are generally quite vascular, and may 
cause considerable obstruction. 



214 PATHOLOGICAL CONDITIONS. 

Tubercles are of rare occurrence in the urethra. 
Cancer occurs only as an extension of the disease from 
the penis, prostate gland or bladder. 

Urinary Calculi. Calculi of different size, form, and 
chemical composition, may be found in the urinary bladder, 
ureters, or sinus of the kidneys. 

Uric, or lithic acid calculi, are the most frequent in their 
presence. They may vary in size, from a pea to that of a 
hen's egg. In color, also, they may vary from a fawn or 
light yellow, to a dark, almost mahogany tint. The sur- 
face may be slightly tuberculated, or smooth, and the interior, 
where a section is made, has a concentric arrangement of 
layers around a central nucleus. 

Oxalate of lime calculi are next in frequency. From the 
strongly tuberculated character of the surface, they are 
frequently known as mulberry calculi. They are of an 
irregular, spherical form, and usually single. In color, they 
are usually of a dark olive or brown, but may be light and 
almost white. They seldom acquire so large a size as the 
lithic acid variety, are very hard, and permit of a high polish. 

Phosphatic calculi are characterized by their softness, 
which permits of their being readily crushed. They are of 
a grayish-white color, and frequently composed of alternate 
layers of other deposits. They may be composed wholly of 
phosphate of lime, or of a triple phosphate — ammonio-mag- 
nesian phosphate — or of a combination of the two. 

Cystine calculi are very rare ; they are yellowish in 
color, of a waxy appearance, and soluble in aqua-ammonia. 

Uric oxide calculi are extremely rare; they resemble uric 
acid calculi, but present a waxy appearance when polished. 



OF THE PENIS. 215 

CHAPTER III. 
THE MALE GENERATIVE ORGANS. 

Section I. OF THE PENIS. 

[Notice : Malformations ; size ; condition of prepuce and glans ; 
chancres, warts, etc. Split open urethra and notice ulcers, strictures, 
etc.] 

Congenital Anomalies. The penis raay be very im- 
perfectly developed, even with a normal development of 
the other organs of generation, although it more frequently 
occurs when the latter are themselves imperfect. 

It occasionally happens that, from an arrest of union in 
the median line of the penis, a slit or fissure is left com- 
municating with the urethra. This commonly occurs in the 
under surface, constituting Hypospadias ; less frequently on 
the upper s.urface, (Epispadias,) and only in cases of extro- 
version of the bladder. 

The prepuce may be wanting. 

Congenital phymosis occasionally occurs, usually associated 
with atrophy of the penis. It is supposed by some, to be 
a predisposing cause of cancer of the penis. 

Hypertrophy and Atrophy. In consequence of long- 
continued onanism, the penis may become hypertrophied, or 
as the result of chronic irritation and disease, we may have 
an hypertrophy of the prepuce and of the body of the penis, 
sometimes attaining an enormous size. Vidal has related 
and figured a case where the organ reached to below the 
knees, and was as large as a thigh. Atrophy of the penis, 
accompanied with obliteration of the cavernous textures, 
occurs with atrophy of the testicles. 



216 PATHOLOGICAL CONDITIONS. 

Fracture of the Penis has occurred from the giving 
way of the erectile tissue during coition, in consequence of 
the state of hyperemia of the penis. The organ appears 
broken, and cannot assume the erect condition beyond the 
part injured. 

Paraphymosis, by the strangulation of the glans in front 
of a tight prepuce, may, if not relieved, lead to inflamma- 
tion, and even gangrene. 

Balanitis commonly occurs as the result of local irrita- 
tion, not unfrequently set up by a gonorrhoea. The prepuce 
is much swollen, infiltrated and reddened. The inflamma- 
ation is generally complicated with inflammation of the in- 
ternal lamina of the foreskin, and the mucous membrane of 
the glans (posthitis), giving rise to excoriation, exudation of 
coagulable lymph, adhesion of the prepuce to the glans, sup- 
puration and ulceration. " When chronic, it induces exu- 
berant formation of epidermis ; and if the deeper parts of 
the parenchyma of the glans are involved, obliteration, 
cartilaginous induration and atrophy follow." 

Herpes of the Glans and Prepuce, is characterized 
by the formation of small vesicles or excoriated points upon 
the mucous membrane of this region, chiefly occurring in 
persons of a gouty habit of body, with an irritable mucous 
membrane. 

Psoriasis of the prepuce, produces a red, thickened, and 
fissured condition of the part. Phymosis is apt to occur as 
a consequence. 

Chancres. These specific ulcerations form usually upon 
the glans, although they may be found in the internal 
surface of the prepuce, the frsenum, and near the meatus 
within the urethra. 



OF THE PENIS. 217 

The Hunter Ian or hard chancre, is nearly circular, deep 
and excavated; base and edges are as hard as cartilage, but 
the hardness is circumscribed; its color is livid or tawny. It 
may occur upon the integument, the glans, or the body of: 
the penis. 

The non-indurated or soft chancre is more frequently 
found on the inner surface of the prepuce. It appears as a 
foul, yellowish, or tawny sore. Indolent fungous granula- 
tions are subsequently thrown out, unless it be situated upon 
the glans. 

Phagedenic chancres are of irregular shape, their edges 
rao-o-ed or undermined, their surface yellow and dotted with 
red streaks. The surrounding margin of skin usually looks 
pulpy and cedematous ; but is sometimes firm and of a 
vivid red. 

The cicatrices left by chancres which have healed, are 
whitish, more or less hard, striated and depressed. 

Morbid Growths. 

Warts, belonging to the class of epithelial tumors, some- 
times form on the glans, or on the inside of the prepuce. 
They are commonly the result of repeated inflammations. 

Cancer of the penis is of two distinct kinds, occurring as 
scirrhus or as epithelioma. According to Dr. Walshe, the 
disease may originate as a warty excrescence, or as a pimple, 
which discharges an excoriating fluid, scabs, and breaks out 
afresh, w T hile induration, followed by ulceration, advances at 
its base. Or it may infiltrate the glans, so as to convert 
that part into an indurated mass ; or venereal ulcers may 
take on cancerous action. 

When of the scirrhus form, it usually springs from the 
ulcers behind the glans, and may thence invade the neigh- 
boring parts of the organ. 

Epithelioma, commencing as a tubercle in the prepuce, 



218 PATHOLOGICAL CONDITIONS. 

may after a time give rise to a large, irregular, and sprout- 
ing mass, having a granular fungous appearance. In other 
cases, it commences as a hard scirrhus mass, of a pale, 
reddish-white color, situated on the glans, or between the 
prepuce and the glans. This increases in size, cracks, and 
allows the exudation of a serous fetid discharge. Ulceration 
then, rapid ly takes place. 

Secondary cancers, except in the adjacent glands, are not 
a common occurrence. Phymosis and the irritation caused 
by the retained secretion, seem to act as an exciting, and 
advancing age as a predisposing cause of cancer. 

Encysted tumors, ncevus and fibro-plastic tumors, situ- 
ated about the prepuce, may also occur. 



Section II. OF THE SCROTUM. 

[Notice: General condition; relaxed or contracted; oedema;- can- 
cer; tumors, etc.] 

Hypertrophy. Oommon hypertrophy of the integument 
of the corium sometimes occurs ; in this there is no altera- 
tion of the subcutaneous tissue. 

In Elephantiasis of the scrotum, however, the epidermis, 
the corium, and the subcutaneous areolar tissue, are all, 
especially the latter, greatly hypertrophied. The areolar 
tissue is converted into a large mass of fibrous material, 
infiltrated with an albuminous and fibrinous fluid. " When 
the disease is confined to the scrotum, and the enlargement 
becomes great, the penis becomes drawn in and ultimately 
disappears, while the elongated prepuce is continuous at a 
navel-like opening in the skin of the surface of the tumor." 
The enlargement sometimes is enormous, such a mass 
having been known to weigh two hundred pounds, more 
than the weight of the rest of the body. 



OF THE TESTICLES. 219 

Inflammatory CEdema of the scrotum is an erysipela- 
tous inflammation of this region, giving rise to great effusion 
into and swelling of the areolar tissue, with a tendency to 
the rapid formation of a slough, by which the integument 
may become so affected as to leave the testes and cords 
entirely denuded. A peculiar form of this disease occurs as 
a sequence of small-pox and scarlet-fever. Here there is a 
tendency to speedy gangrenous disorganization of the areo- 
lar tissue, and of the covering of the generative organs. 

Morbid Growths. 

Cancer. Ejnthelial cancer is the common form under 
which it attacks the scrotum. This disease has appropri- 
ately been called chimney-sweeper s cancer, as it appears to 
arise from the irritation of the soot lodging in the folds of the 
scrotum. It commonly commences as a tubercle or wart, 
which, after a time, cracks or ulcerates. It spreads rapidly, 
involving at last the greater part of the- scrotum, and some- 
times invading the testes, even extending to the groin and 
thigh, destroying life by perforating the coats of some of the 
large vessels. The glands of the groin are not always 
affected. 

Melanotic cancer of the scrotum has been observed. 

Fibrous tumors are sometimes developed in this part, and 
may form a large mass when several are grouped together. 



Section HE. OF THE TESTICLES. 

[Notice : Malformations ; position, in scrotum, inguinal canals, or 
abdomen. Size; consistence; condition of coats. Tunica vaginalis — 
contents ; serum, blood ; adhesions. Abscesses ; cysts ; tumors ; can- 
cer ; tubercle, etc.] 

Congenital Anomalies. There is no sufficient evi- 
dence of the presence of more than two testicles. They are 



220 PATHOLOGICAL CONDITIONS. 

both absent when the entire sexual apparatus is wanting, 
and in some rare cases they are imperfectly developed, or 
only one may exist. 

It not unfrequently happens that at birth there is an ap- 
parent absence of one or both glands from an arrest or 
delay in their descent, so that they lie in the groin, the 
inguinal canal, or the lower part of the abdomen. Some- 
times they wander into other situations, e. g., into the peri- 
neum close by the anus, and through the crural canal. If the 
descent does not take place within twelve months after birth 
it is rarely perfectly completed afterwards without being 
accompanied by hernia. 

The organ is sometimes retro verted, so that the epididymis 
is placed in front. 

The vas deferens may be absent to a greater or less 
extent, and even the epididymis has been found in great 
part deficient. 

The vas deferens frequently terminates in a blind extremity 
before reaching the vesicula seminalis. 

Hypertrophy and Atrophy. True hypertrophy of 
the testicles does not occur but when attacked with inflam- 
mation, or when the seat of morbid growths the glands may 
become greatly enlarged. Atrophy, congenital or acquired, 
is not unfrequent. The effect of old age is very gradual, the 
gland being often but very little diminished in size. 

" The testicle atrophied from disease is not only of dimin- 
ished size and weight, but is altered in shape, being uneven 
and irregular, and sometimes of an elongated form. There 
is little or no trace of the proper glandular structure, the 
organ being converted into fibrous tissue of a firm texture. 

" The testicle in an advanced stage of wasting, notarising 
from disease of the gland, usually preserves its shape, but feels 
soft, having lost its elasticity and firmness. Its texture is 
pale, and exhibits few blood-vessels; the lobuli and septa 



OF THE TESTICLES. 221 

dividing the lobes are indistinct, and the former cannot be 
so readily drawn out into shreds as before. The epididymis 
does not usually waste so soon, nor in the same degree as 
the body of the testicle. Fatty matter is also found in the 
glandular substance of atrophied testicles." 

Inflammation. The serous covering of the testes, the 
tunica vaginalis, is liable to acute inflammation, and is then 
affected as other serous membranes. It becomes thickened 
and injected with blood, and is coated with a variable 
quantity of fibrinous exudation. Serum is, at same time, 
effused into the cavity, and rendered turbid by flakes of fibrin. 
Adhesions between the opposing surfaces commonly form. 
The epididymis is apt to partake of the inflammation of the 
tunica vaginalis, and vice versa. 

Orchitis and Epididymitis, may be acute or chronic, 
primary or secondary. In acute cases, the testis is con- 
gested, and of a darker hue than natural, although not much 
enlarged. The epididymis, especially its lower part, is 
much enlarged, and feels thick, firm and indurated. " The 
coats of the vas deferens are thickened, and the adjacent 
vessels injected. The tunica vaginalis is inflamed, and its 
cavity contains the usual effusions." 

Suppuration may occur more frequently in primary 
orchitis, rarely in the secondary form. The pus is liable 
to burrow and disorganize the tissue of the gland. By a 
subsequent absorption of the fluid part of the pus, there is 
often left a whitish mass resembling tubercular deposit, but 
distinguished from this by being contained in a cyst, and by 
the altered condition of the adjacent gland tissue. The 
epididymis not unfrequently remains enlarged, presenting a 
hard, knotty swelling at its lower part. " In old cases the 
epididymis acquires the density and consistence of cartilage, 
and sometimes even of bone." 

Atrophy of the gland is a frequent result of inflammation. 



222 PATHOLOGICAL CONDITIONS. 

Chronic orchitis is characterized by the effusion of a 
yellowish, homogeneous-looking matter, in the substance of 
the testicle, within the tubuli. This deposit may shrink 
and contract, inducing gradual atrophy of the testis, or, by 
adhesions and ulcerative absorption, a fungous protrusion of 
the affected, tissue may take place. 

Hydrocele. Simple Hydrocele is a dropsy of the tunica 
vaginalis. The fluid is usually clear, and of a straw color, 
sometimes turbid, with albuminous flocculi, and not unfre- 
quently contains shining particles of cholesterine. In old or 
very large hydrocele, it is often dark-brown or chocolate 
colored from disintegrated blood. Its quantity is sometimes 
very considerable. The position of the testicle may be 
altered by adhesions formed between the two layers of the 
tunica vaginalis ; these latter may also produce a multiloc- 
ular hydrocele. Simple hydrocele may occur with some of 
the other varieties to be mentioned, and also with inguinal 
hernia. 

When serous effusion in the tunica vaginalis, is asso- 
ciated with chronic orchitis or other diseases of the gland, 
we have hyclro-sarcocele. 

In congenital hydrocele, the dropsical tunica vaginalis 
retains its foetal communication with the peritoneal cavity. 

Encysted Hydrocele. In this variety the fluid is con- 
tained in cysts, which may be situated (1) beneath the visceral 
portion of the tunica vaginalis, investing the epididymis; (2) 
between the testicular portion of the tunica vaginalis and the 
tunica albuginea, which are thus separated from each other ; 
(3) between the layers of the loose or reflected portion of the 
tunica vaginalis. The two last mentioned varieties are of 
rare occurrence. The cysts have thin fibrous walls, a 
lining of tessellated epithelium, and contents usually clear, 
although sometimes mixed with various exudations of fibrin 
or even blood. Spermatozoa are very frequently found in 



OF THE TESTICLES. 223 

the fluid of these cysts. Their presence is undoubtedly due, 
as pointed out by Cushing, to the rupture of a neighboring 
seminal duct. They are but rarely found in the fluid of 
common hydrocele. 

Diffused Hydrocele of the Cord, gives rise to an oval or 
oblong, irregular, circumscribed tumor, extending below and 
into the inguinal canal. " It consists in the enlargement of 
the cells of the areolar tissue, and their distension with a 
white or yellowish serous fluid. The inclosing fascial 
sheath is condensed and thickened, and at the lower part of 
the swelling, which is always the largest, separates it com- 
pletely from the tunica vaginalis." 

Encysted Hydrocele of the Cord forms a tumor of oval 
shape, loosely attached to the vessels of the cord which pass 
behind it. Instead of a single cyst, there may be a number, 
forming a series along the cord. 

Hematocele, is a tumor formed by an effusion of blood 
from the vessels of the testis or of the spermatic cord, into 
the cavity of the tunica vaginalis. It may be traumatic or 
spontaneous, and may attain a large size. Coagula are 
formed either in separate masses, or in firm layers, as in 
aneurism. Inflammation may be set up, leading to fibrinous 
and serous efTusion, and to suppuration, or the blood may 
putrify and gangrene result. The tunica vaginalis is com- 
monly thickened, the testicle unaffected, or in old cases 
atrophied from pressure. 

Diffused Hematocele of the Cord results from the rup- 
ture of some vessels of the cord, in consequence of which 
blood is effused within the spermatic fascia. A tumor of 
enormous size may be formed should the bleeding continue, 
or recur after having been arrested. The usual cause is 
some strain or violent exercise. 

Varicocele is a morbid dilatation of the spermatic veins. 



224 PATHOLOGICAL CONDITIONS. 

"The enlarged veins hang; down below the testicle, and reach 
upwards into the inguinal canal ; and when very volumi- 
nous, conceal the gland, encroach on the septum, and 
extend to the other side of the scrotum." The left veins are 
more frequently affected than the right. In an advanced 
stage of the disease, the coats of the veins are thickened, 
and do not collapse when cut across. In cases of slight 
varicocele, the nutrition of the testis is not interfered with, 
but when large, it produces marked atrophy. 

Morbid Growths, 

Cancer is most frequently primary, and generally attacks 
the body of the testis in the first instance, the epididymis 
remaining for some time unaffected. 

The scirrhus variety, characterized by its great induration, 
is rarely met with. 

Micep haloid is the ordinary form; it commences as one 
or two masses among the tubuli, which it gradually destroys. 
The tunica aibuginea is absorbed by degrees, gives way, and 
allows the growth to project into the scrotum and there 
freely vegetate. The scrotum is slow to be involved in the 
disease, but at first becomes distended, sometimes to the size 
of a cocoanut, and then gradually ulcerates. The spermatic 
artery and the accompanying veins become greatly enlarged. 
The cord may also be attacked with the disease, while sec- 
ondary cancers spring up in various places. The lymphatic 
glands in the neighborhood become enlarged, especially 
those in the iliac fossa. The inguinal glands do not gener- 
erally become affected until the skin has become involved in 
the disease. 

Intermixed with the encephaloid are commonly found 
masses of a bright yellow color, supposed by some to be de- 
posits of tuberculous matter, but by others, merely plastic 
matter undergoing fatty degeneration. 



OF THE TESTICLES. 225 

Colloid and melanotic cancers have rarely been observed 
in the testes. 

The tunica vaginalis is said to have been attacked with 
cancerous disease, the testis remaining healthy. 

Cystic Disease of the Testis. The cysts may be 
but few, or very numerous. The testis is proportionately 
enlarged, indurated, of a yellowish-white and opaque appear- 
ance, and studded with cysts varying in size. The contents 
are, in the younger cysts, a clear, amber-colored fluid ; in the 
older ones, more thick, viscid, highly albuminous, and of a 
brownish color. The cysts are sometimes imbedded in solid 
stroma, probably of fibroid tissue ; sometimes small masses of 
enchondroma are found between them. When of an inno- 
cent character, the cystic disease is characterized by the 
presence of tessellated epithelium in the cysts ; when malig- 
nant, by the presence of nucleated cancer cells. 

"Occasionally cystic tumors of the testicle are met with, 
in which the substance of the organ is atrophied or absorbed, 
and its place occupied by one or more large thin-walled 
sacculi containing fluids of different color and consistence, 
dark or fatty." 

Tubercles are not very unfrequent, and appear some- 
times in the body of the gland, but oftener in the epididymis, 
whence they may spread to the testis. They occur as gray 
granulations, infiltrated or encysted, and varying in size 
from a pin's head to a plum- stone. They are commonly 
found in all stages of development and disintegration in the 
same organ. Their presence in and between the tubuli 
produces inflammation, suppuration and disorganization of. 
the structure of the testis, with which they become mixed,, 
so as to form a cheesy mass of a dirty bufT color. This may,, 
by ulceration, perforate the scrotum, and protrude as a 
fungous growth of a pale, reddish-yellow granular mass.. 

15 



226 PATHOLOGICAL CONDITIONS. 

This disease of the testis is frequently found in connection 
with pulmonary tubercle, or general tuberculosis. 

Tubercular syphilitic sarcocele, described by Hamilton, of 
Dublin, is a variety occurring in an advanced stage of con- 
stitutional syphilis. 

" Cretaceous matter is occasionally met with in the testis, 
doubtless the residue of tuberculous deposit which has 
softened and undergone calcareous change." 

Tumors. Fibroid tumors of small size are sometimes 
■found developed within the visceral layer of the tunica vagi- 
nalis, or within the substance of the cord. 

Fatty tumors may be found, which have originated within 
the tunica albuginea, the dartos, or within the fibrous con- 
nective tissue of the cord. 

Cartilaginous tumors of small size, originate with the 
substance of the gland, and are frequently associated with 
cystic disease or cancer. 



Section IV. THE SEMINAL VESICLES AND 
PROSTATE. 

[Notice: 1. Seminal vesicles — present or absent ; size; distended 
or empty ; contents. Condition of mucous lining; inflamed, thickened, 
ulcerated, perforated; tubercular deposits, etc. 2. Prostate gland — 
abnormalities; size; density; enlargement of middle or lateral lobes; 
color of section ; appearance of inflammation ; abscess; tumors; cancer; 
tubercle. Contents of ducts — calculi: their position, size, etc.] 

Congenital Anomalies. The vesiculse seminales par- 
ticipate in the defective development of the testes, being 
absent or imperfect when their related glands are so. 

Inflammation. It is not uncommon for these bodies 
to be attacked with chronic catarrhal inflammation, which 
causes a swelling of their mucous membrane, the secretion 



OF THE SEMINAL VESICLES AND PROSTATE. 227 

of unhealthy mucus, dilatation of the cavity, and thickening 
of its walls. Ulceration, perforation, and the formation of 
abscess in adjacent parts, may result. 

Tubercular Deposits are occasionally met with, chiefly 
in cases of extensive tuberculosis. "It appears as a thick, 
yellow, cheesy, lardaceous, fissured, purulent layer, replacing 
the mucous membrane." It never occurs before puberty. 

The Prostate Gland. 

Congenital Anomalies. When the organs of gener- 
ation are imperfectly developed, the prostate gland is 
generally found to be so too. 

' Hypertrophy and Atrophy. Hypertrophy is of fre- 
quent occurrence, especially in connection with old age. All 
the lobes may be enlarged equally, or nearly so, or one or the 
other of the lateral lobes alone, or the middle lobe, without 
any corresponding hypertrophy of the lateral. Hyper- 
trophy of the middle lobe, when considerable, throws the 
neck of the bladder forward, and increases the depth of its 
.lower region, so that calculi may lodge behind and below the 
prostate in its cavity. The canal of the urethra becomes 
lengthened in its prostatic portion, and may be narrowed by 
compression, or considerably dilated, so that the prostatic 
sinus may contain two or three ounces of urine. The 
retained urine decomposing, may cause irritation and in- 
flammation of the- bladder. 

The texture of the enlarged gland is generally indurated, 
though sometimes it is found to be looser and softer than 
natural. On section, the cut surface bulges above the 
level, and the shades of color are more strongly marked 
than in health. Frequently single gland-lobules are found 
hypertrophied. Small cavities, dilatations of the gland- 



228 PATHOLOGICAL CONDITIONS. 

follicles, are occasionally met with, sometimes empty and 
sometimes containing a yellow, pus-like fluid, the prostatic 
secretion in a thickened state. 

Atrophy, with consolidated texure, is found with atrophy 
of the testes. 

" Eccentric atrophy is occasionally met with ; the cavities 
are dilated and the walls thinned, in consequence of the in- 
crease in size of calculous concretions in its follicles. Cases 
sometimes occur, in which the whole of one lobe, or even 
the entire organ, is converted into a thin fibrous capsule, the 
proper substance of the gland being almost wasted." 

Inflammation. As a result of suppressed gonorrhceal 
discharge, the prostate may be attacked with acute in- 
flammation, followed by suppuration, or chronic enlargement, 
or an irritable state of the gland, with increased secretion. 

Abscesses, single or multiple, may occur, and open into 
the bladder, into the prostatic sinus of the urethra, into the 
rectum, or, externally through the perineum. 

Ulceration rarely occurs. 

Morbid Growths. 

Cancer of the prostate is rare ; encephaloid is almost the 
only form that occurs. The gland is enlarged and the 
growth may perforate the mucous membrane of the bladder, 
and vegetate in its cavity. 

Tubercles occasionally occur. Their softening and disin- 
tegration give rise to abscesses, which pursue the same 
course as inflammatory abscesses. 

Fibrous tumors, varying in size from that of a pea to 
a nut, are of frequent occurrence ; sometimes but loosely 
attached to the hypertrophied gland. 

Oysts are of extremely rare occurrence, commonly result- 
ing from closure and dilatation of the gland-follicles. 



OF TILE SEMINAL VESICLES AND PROSTATE. 229 

Concretions. " In greater or less numbers, they are of 
almost constant occurrence in the prostatic cavities ; they 
may often be seen on making a section of the gland, as 
reddish-yellow grains. Their form varies very much ; in 
the smaller it approaches the oval or circular ; in the larger 
it is more polygonal or triangular. They are not unfre- 
quently pale or colorless. The contents of these semi- 
organized formations appear to be earthy matter (phosphate, 
with a little carbonate of lime), tinged by the ordinary 
yellow pigment which is so often derived from the blood. 

It is most probable that, in ordinary healthy states, these 
concretions undergo solution at an early period of their 
existence, yielding up their contents to form part of the 
secretion of the gland. But, if this does not occur, and 
they go on increasing in size, they become the nuclei, or are 
" developed into prostatic calculi. These are not unfrequently 
very numerous ; as many as fifty or sixty have been found 
in an atrophied, dilated prostate. The calculi sometimes 
cohere, and form a large mass, projecting into the mem- 
branous portion of the urethra, which becomes in conse- 
quence much dilated. The smaller calculi often escape into 
the bladder through the dilated prostatic ducts ; if they 
remain there, they excite irritation of the mucous mem- 
brane and deposition of phosphates upon their own surface." 



230 PATHOLOGICAL CONDITIONS. 

CHAPTER IV. 

THE FEMALE GENERATIVE ORGANS. 

• Section I. THE PUDENDA AND VAGINA. 

[Notice : 1. Of the pudenda — malformations ; condition of the 
labia and clitoris ; size; color; abrasions; ulcers; eruptions; tumors; 
marks of violence, etc. Orifice of urethra — growths around, their 
number and size. Hymen — present or absent ; entire or lacerated ; 
imperforate.] 

1. The Pudenda. 

Congenital Anomalies. In rare cases the external 
organs are entirely absent, more frequently but partially 
developed. 

The nymphse may be found abnormally enlarged. 

The clitoris may be abnormally long, perforated, or cleft. 

Many of the cases of so-called hermaphroditism are in- 
stances of an undue congenital development of the clitoris, 
with an irregular development of the other organs of genera- 
tion, either external or internal, or both. 

Hypertrophy. We may find an hypertrophy of the 
labia, due to a kind of solid oedema, perhaps originally 
dependent upon a fissure or ulcer of the part. The nymphse 
are often abnormally enlarged, not necessarily as the 
result of an abuse of sexual indulgence. In new-born 
infants, they normally project beyond the labia majora. 
The clitoris occasionally is enlarged, elongated and pendu- 
lous, and, in some cases, attains an enormous size. A 
specimen preserved in the Museum of the University of 
Bonn, is fourteen inches in circumference and weighs eight 
pounds. There is no necessary connection between an 
habitual sexual indulgence and an enlarged clitoris. 



OF THE PUDENDA. 231 

Varicose swellings of the labia may reach a considerable 
size, and, although not generally interfering with parturition, 
bave been known to be lacerated at that time with fatal issue. 

As the result of external violence, or during parturition, 
sucro-illations often occur in the labia, and mav give rise to 
considerable swelling. The tumor presents a tense, smooth 
surface, of a livid color, thus distinguished from a varicose 
swelling, with the peculiar vermicular character of its 
contents. 

Inflammation. The cutaneous covering, the mucous 
lining, the cellular tissue, and the sebaceous and mucous 
follicles, may be the seat of inflammation, resulting from 
external or internal causes. 

Eczematous and apthous inflammations may result from 
derangement of the digestive organs, from pregnancy, from 
a want of cleanliness, or from excessive sexual indulgence. 
and are of frequent occurrence. 

The loose cellular tissue is especially favorable to cedema- 
tous swelling, and when the inflammation has a phlegmonous 
character, extensive sloughing may result. It occasionally 
occurs as an epidemic among those in early life. 

The vulvo-vaginal glands are also liable to inflammation 
of a catarrhal, herpetic or syphilitic character, resulting in 
chronic ulceration, or tedious discharges. Young; children 
are frequently liable to a benignant inflammatory affection 
of these parts, giving rise to much irritation and a muco- 
purulent secretion. 

Morbid Growths. 

Warty excrescences, arising from a syphilitic taint, may 
affect the labia, the entrance of the vagina, and the clitoris. 
They consist of groups of small pedunculated tumors, 'pro- 
ducing a sort of mushroom appearance. 



232 PATHOLOGICAL CONDITIONS. 

Syphilitic mucous tubercles are described as round, flat- 
tened tubercles, raised above the surrounding tissues, some- 
times becoming elongated, of a reddish-blue color, and 
frequently ulcerated on the surface. 

Cystic tumors are also met with in the labia. • They con- 
sist of a membranous envelope, containing a transparent, 
glairy fluid, and often attain a large size. 

The mucous membrane surrounding the orifice of the 
urethra, is liable to an hypertrophy of development, giving 
rise to small vascular, generally pedunculated tumors, ex- 
tremely sensitive during life, and liable to become abraded. 

Mepha?itiasis may attack the labia majora, the nymphge, 
or the clitoris, and may attain to a great size. It consists of 
the loose connective tissue of the part, infiltrated with serum, 
and covered either with the smooth skin, or one which has 
become roughened by hypertrophy of the papillae. It may 
appear as a diffused hypertrophy, or be furnished with a 
pedicle, and resemble a polypus. 

Fibrous, fatty and scirrhus tumors are also met with 
in this part of the system. 

2. The Vagina. 

Congenital Anomalies. The valvular fold of mem- 
brane which protects the virgin vagina, the hymen, may be 
imperforate or much indurated, and of a cartilaginous con- 
sistency. It may thus entirely close the vagina. Besides 
this, we may find the vagina terminating in a cul-de- 
sac, either with the uterus present or absent, and the 
ovaries normal or abnormal. The vagina may also be 
duplicated, by a septum extending the entire length of the 
canal, or only partially dividing it. There may be at the 
same time a double uterus. Entire absence of the vagina is 
also met with, the internal organs of generation being also 
absent, or but imperfectly developed. 



OF THE VAGINA. 233 

Morbid States. Occlusion or stricture of the vagina 
sometimes occurs as the result of external injury, or of 
cicatrization of ulcers. 

Dilatation, or lengthening of the vagina, also occurs. 

The rigidity or laxness of the walls of the vagina, varies 
much in different individuals, according to constitution, age, 
and the effects of cohabitation and child-birth. Prolonged 
uterine or vesical disease, often produces a very lax condi- 
tion of the mucous membrane of the vagina. In old women 
we often meet with this relaxed state, which may amount 
to a complete prolapsus. The anterior wall is particularly 
liable to be thus affected. 

Laceration and Rupture. External mechanical in- 
juries may produce laceration of the vagina. During par- 
turition, either from unusual rigidity, or from want of care 
on the part of the attendant, the lower portion of the canal 
is apt to give way when the labor pains are at their height, 
The lesion may vary from a mere laceration of the fourchette, 
to a rupture of the entire perineum, from the vagina to the 
anus. Lacerations of the upper portions of the vagina also 
occur with rupture of the uterus, or even independently of it. 

Lacerations of the vagina are not necessarily fatal, but 
may result in vesico-vaginal fistula, where a communica- 
tion is established between the bladder or urethra, and the 
vagina; or in recto-vaginal fistula, where the fistula opens 
into the rectum. 

Inflammation. The mucous membrane of the vagina 
is frequently the seat of inflammation. The commonest 
form is the catarrhal, which may be acute or chronic. In 
the first stage, the passage is reddened, heated and dry. 
This is followed by an abundant secretion of white, creamy 
mucus ; or of a more purulent discharge, if the inflamma- 
tion has anything of a specific character. 



234 PATHOLOGICAL CONDITIONS. 

Croupous inflammations, in connection with general dis- 
ease, or a similar disease of the uterus, may occur. They 
produce a solution of the mucous membrane and the sub- 
mucous tissue, varying in shape and depth, and not un- 
frequently resembling gangrenous destruction. (Rokitansky.) 

A chronic thickening of the mucous membrane, as the 
result of inflammation, is occasionally met with. 

The follicular, syphilitic and carcinomatous ulcer also 
affect this part. 

/Suppurative inflammation may result from injuries, end- 
ing in the formation of an abscess in the fibrous structures, 
which may burrow within the pelvic areolar tissue, or extend 
into the labia. 

Gangrene sometimes results from injuries received during 
parturition, or from a degeneration of croupous inflamma- 
tion in a vagina affected with blenorrhcea of a gonorrhceal 
or syphilitic origin. 

Morbid Growths. 

.Polypi and cysts are the varieties most frequently met 
with in this situation. The polypi may be either fibro- 
vesicular, or cellulo-vascular, varying greatly in size. The 
encysted tumors, originate in an obstruction of the follicles 
of the part, and contain a glairy, transparent, greenish, or 
dirty-brown albuminous fluid. 

Myomatous tumors may be found developed within the 
muscular coat of the vagina, the posterior Avail being their 
usual position. 

Carcinoma may occur primarily, or by an extension of 
the disease from the cervix uteri. 

The form in which it appears is the encephaloid kind, the 
appearance of which is described in connection with the 
uterus. 

Malignant epithelial growths are not met with in the 
vagina. 



OF THE UTERUS. 235 



Section II. OF THE UTERUS. 

[Notice : 1. In situ — absence or malformations. Size, and rela- 
tion to surrounding organs and walls of pelvis: high or low in pelvis; 
versions; flexions; adhesions, etc. 2. After removal — os ; size and 
shape, round, oval, irregular, etc. Lips — size; form; color ; condition 
of surface; soft or firm; rough or smooth; abrasions; granulations; 
ulcers; tumors, etc. External characters of hody — size; measure- 
ments; weight; tumors; rupture; consistence, hard or soft. After 
section — thickness of walls ; density ; condition of blood-vessels ; ab- 
scesses; tumors, etc. Uterine cavity — size and form. Contents; serum; 
size and condition; blood; mucus; pus; tumors. Condition of mucous 
lining, cancerous growths, etc.] 

According to the measurements of Kilian, the uterus 
in the virgin adult, varies in length from twenty-four to 
twenty-six lines ; the greatest breadth is eighteen lines ; 
the thickness nine lines ; the cervix is from ten to twelve 
lines long ; its breadth from six to eight ; its thickness 
from five to six lines. The length of the uterine cavity 
is twelve lines, and its breadth nine lines. After one or 
more births all these measurements increase from one-fifth to 
one-quarter. The weight of the uterus varies from eight to 
twelve drachms, and may, after several pregnancies, amount 
to two ounces. 

Congenital Anomalies. The entire absence of the 
uterus is an exceedingly rare occurrence, and need not affect 
the health of the individual. A seeming multiplication of the 
organ is occasionally met in the bilocular and horned uterus. 
In the former, a more or less perfect septum extends through 
the organ in the median line, while in the latter, the uterus 
is divided into two lateral portions, by a prolongation of the 
angles or cornua, giving a resemblance thus to a permanent 
form seen in many of the lower animals.* We may also find 
the so-called uterus unicornis, where only one of the two 

* See No. 359, College Museum. 



236 PATHOLOGICAL CONDITIONS. 

rudimentary bodies from which the normal uterus is devel- 
oped arrives at maturity. 

All these kinds of uteri are capable of becoming im- 
pregnated, but parturition, although not necessarily fatal, 
seriously endangers the life of the patient ; owing, according 
to Robitanshy, partly to the want of the necessary dimen- 
sions of the part that undertabes the functions of the entire 
organ, and partly to the obstacle opposed to the uniform 
development of the impregnated half by the unimpregnated 
half. These circumstances favor rupture of the uterine walls. 

Hypertrophy and Atrophy. These are in part normal 
at the periods of puberty and change of life ; as a morbid 
state, the first is of more frequent occurrence than the last. 
Either may affect the entire organ, or only a part. After 
the climacteric period the cervix often disappears entirely. 

Hydrometra. As the result of inflammatory processes, 
the os internum or the os externum may become occluded, 
causing a retention of the secretions from the diseased 
mucous membrane of the uterus. This secretion gradually 
chancres into a sort of thin serum. The uterus becomes 

o 

dilated, and we have hydrometra. 

Hcematometra is a condition where the uterus is dilated 
with serum mixed with blood, or exclusively with retained 
menstrual blood. This latter state is more frequently the 
result of congenital than of acquired atresia. 

The amount of dilatation may vary greatly. 

Malpositions of the Uterus. These may be of two 
binds: (1) where the direction of the axis is changed; or (2) 
the organ becomes altogether displaced, so that its relation 
to all the pelvic viscera is altered. Of the former class, are 
ante- and retro-versions, with flexions, and lateral obliquities; 
of the latter, prolapsus procidentia and inversion. 






OF THE UTERUS. 237 

Inversion may occur spontaneously or as the result of 
manual interference in the removal of the after-birth. The 
fundus may pass but a short distance into the cavity of the 
organ, or the uterus may be turned completely inside out. 
Inversion may also result in an unimpregnated uterus from 
the presence of fibrous polypi, growing from the inner sur- 
face of the fundus. These growths, when complicating 
pregnancy, favor inversion by disturbing the regular expul- 
sive contractions. 

Haemorrhages. An effusion of blood into the cavity 
of the uterus, occurs normally at every period of menstrua- 
tion ; from some morbid condition of the vessels of the 
uterus, it may at times amount to an haemorrhage. Attend- 
ing parturition, it may be due to placenta praevia ; or fol- 
lowing, to atony or defective contraction of the uterine 
walls, where we find the uterus maintaining its dilated con- 
dition with flabby and soft walls ; or to spasm or irregular 
contraction, to which the term, " hour-glass contraction," 
has been applied. 

The presence of polypoid tumors is frequently attended by 
haemorrhages. 

Peri- or Retro-uterine Haematocele, is an accumu- 
lation of menstrual blood, generally in the utero-rectal cul- 
de-sac. It may arise from rupture of a blood-vessel, from 
defect in the excretion of the menses, or form a morbidly 
profuse exhalation of blood from the genital organs. The 
extravasation may be reabsorbed, or may by perforation be 
discharged by the rectum or vagina, or may lead to suppu- 
ration and the formation of an abscess. 

Inflammations. The traces of acute catarrhal in- 
flammation are but seldom to be discovered. They present 
the same features as catarrhal inflammations of other mu- 



238 PATHOLOGICAL CONDITIONS. 

cous membranes, congestion and swelling, with a more or 
less abundant secretion of muco-pus. 

In chronic catarrhal inflammations, the membrane is 
found thickened, of a brownish or slate-gray color, with a 
more or less purulent secretion, often blood-streaked. The 
walls of the uterus may be atrophied or hypertrophied. 

"Catarrhal erosions, and follicular ulcers, the result of the 
bursting or suppuration of the stopped-up follicles, usually 
accompany catarrhal inflammations. 

Acute Metritis. Here we find the organ swollen and 
congested, and its substance of a darker color. The mucous 
membrane shows symptoms of a catarrh, and the peritoneal 
covering is also congested. Occasionally extravasations of 
blood are found in the substance or cavity of the uterus. 
The inflammation may lead to the formation of abscesses 
within the uterine walls. 

In Chronic Metritis the organ is generally much 
enlarged. The walls are remarkably pale and dry, thick 
and hard. The mucous membrane almost always pre- 
sents the appearances described under chronic catarrhal 
inflammation, while the peritoneal covering frequently 
shows numerous adhesions to the neighboring organs. 

Ulcerations may be catarrhal, with superficial erosions 
or follicular ulcers ; or syphilitic, in the form of the hard 
and soft chancre ; or we may, in rare cases, have the corrod- 
ing ulcer, described by Dr. John Clarke, and differing from 
genuine carcinoma only in the absence of an indurated 
deposit. 

Morbid Growths. 

Fibroid tumors are of most frequent occurrence. They 
are found either imbedded in the texture of the uterus, or 
protruding from its inner surface into the cavity, or from 
some part of its external surface. 



OF THE UTERUS. 239 

Those projecting into the cavity of the uterus, called also 
fibrous polypi or submucous tumors, are most frequently 
met with. Their pedicles are generally situated just below 
the openings of the Fallopian tubes, although they spring- 
also from the posterior wall and from the fundus, less 
frequently from the anterior wall, and still more rarely from 
the cervix uteri. 

Recent investigations go to show that these tumors are to 
be classed with the homologous, rather than heterologous 
productions, and that they are developments of true muscu- 
lar tissue. To the naked eye this structure varies in some 
respects ; at times they present a concentric disposition of 
fibres, but more commonly an irregular, wavy appearance, 
without any uniformity of arrangement, and in the latter 
case, frequently with cavities containing blood, a dark- 
colored gelatinous fluid, or a clear serum. Under the 
microscope, a fibrous structure is scrircely perceptible, but 
elongated nuclei are seen, imbedded in an amorphous 
stroma. 

The vascularity of fibrous tumors varies. The majority 
are but scantily provided with vessels. The tumors 
imbedded in the uterine tissue form globular, white, glisten- 
ing, dense tumors. There may be only one, or they may be 
numerous, and may vary in size from that of a pin's head to 
that of a melon. These growths are subject also to secon- 
dary changes ; thus we may find abscesses in the very 
centre of fibroid growths, or they may contain encysted 
melanotic tumors, or a species of calcification may be 
developed. 

Fibrous tumors have not been observed before puberty, 
but occur, according to Lee and Bayle, most frequently in 
virgins. 

Polypi and Polypoid Growths. These growths — 
not to be confounded with the fibrous tumors, as is fre- 



240 PATHOLOGICAL CONDITIONS. 

quently done — are soft and succulent, and project into the 
cavity of the uterus, or hang into the vagina. They are 
attached by a pedicle of greater or less width, to the 
surface from which they spring, and are covered with 
the mucous membrane of the part. They are essentially 
a morbid condition of the structures of the surface, the 
mucous membrane, the follicles, or sebaceous crypts of the 
different parts of the uterus.* 

Polypoid tumors may give rise to haemorrhages. They 
may become inflamed, suppuration or even gangrene super- 
vening. In this way the pedicle may be destroyed, and the 
tumor be expelled. 

Cysts and Tubercular Deposits are extremely rare 
in the uterus. The latter affect primarily the lining mem- 
brane, where it occurs in the miliary form, or accumulated 
in masses, aggregated into nodules, or forming a cheesy layer 
over the entire surface. The uterine tissue may be secon- 
darily affected, and is then liable to become infiltrated with 
the morbid product. Traces of the disease are found also in 
the vagina as spots of ulceration, and in the Fallopian tubes. 

Cancer. Carcinoma of the uterus is of frequent occur- 
rence. The period of life in which it is most frequently 
met with, is that between the fortieth and fiftieth years. 
Although met with in single women, it is found most fre- 
quently among the married. 

In general, this disease attacks the cervix first, whereby 
it is distinguished from fibroid growths. 

Many instances of supposed cancers, prove on microscopic 
examination, to be nothing more than an irregular thicken- 
ing and induration of the cervix, consequent upon chronic 
inflammation. 

* See No. 329, College Museum. 



OF THE UTERUS. 241 

According to Rokitansky, the prevailing form of uterine 
cancer is the medullary carcinoma, appearing as an infiltra- 
tion of a white lardaceo-cartilaginous, or loose encephaloid 
matter, in which the uterine tissue is lost, and giving rise to 
the characteristic nodulated surface of the cervical portion of 
the orsjan. 

Of rarer occurrence is the fibrous cancer, consisting of 
dense, whitish, reticulated fibres, containing in their meshes 
a pale-yellowish translucent substance. Its limits are not 
sharply defined, but are lost in the uterine tissue. 

Nowhere does the destructive character of the cancerous 
disease manifest such virulence, as when attacking the 
uterus. The degeneration spreads more or less rapidly to 
the adjoining parts, and, in extreme cases, the whole con- 
tents of the abdomen are matted together, and present a 
frightful spectacle of disorganization and destruction. 

Cauliflower Excrescence of the cervix, is regarded by 
both Rokitansky and Henaud, as a modification of encepha- 
loid growth. It appears as an irregular projection, with a 
base as broad as any other part of it, attached to some part 
of the cervix. The surface has a granulated feel. On 
removal from the body it collapses, owing to its vascular 
character.* 



Morbid Conditions following Parturition. 

Rupture of the Uterus is not unfrequent as a concomi- 
tant of pregnancy in the horned or bilocular malformation 
of the organ. It is also met with in the normal uterus. "j* A 
laceration of the os tinea? occurs at every birth, and so long 
as it does not extend beyond the circular fibres of the cervix 

* See No. 331, College Museum. 
f See Nos. 335 and 360, College Museum. 

16 



242 PATHOLOGICAL CONDITIONS. 

is not dangerous. The result is generally more disastrous 
when the rupture extends beyond this point. It may pene- 
trate the entire thickness of the organ, so as to allow of the 
escape of the foetus into the abdominal cavity, or only one 
layer of the walls may give way, or only the peritoneal 
investment may be lacerated, while the uterus itself remains 
uninjured. Rupture of the uterus may also result from 
•external injury before parturition. It is not necessarily 
fatal. Primiparse are more liable to this accident than 
multiparas. 

Puerperal Inflammations. Where the uterus has 
itself been the main seat of inflammation, we find that an 
exudative process has given rise to the formation of a yellow- 
ish or greenish, more or less, gelatinoid lining on its internal 
-surface, causing a ragged, patchy appearance. This exuda- 
tion may be easily detached from the subjacent mucous 
membrane, which, according to the intensity of the disease, 
is more or less reddened, tumefied and softened. This con- 
dition may penetrate to the deeper tissues, and involve the 
entire thickness of the uterus, which will then, also, be 
more or less softened and discolored, infiltrated with a thin 
sanious product, and even converted into a mere pulp. 

The dirty-colored, brownish, flocculent matter that is 
found investing the inner surface of the uterus soon after 
delivery, and which is merely the residue of the decidua, 
must not be mistaken for the product of disease. The 
ragged appearance of the part to which the placenta was 
attached, due, according; to Dr. John Clarke, to the remains 
of the maternal portion of the placenta and the coagula of 
blood left after its separation, is also liable to be the source of 
error. In both cases, however, if the apparent exudation 
■be scraped off, which can easily be done, we find the 
healthy surface underneath. 

In putrescence, the lowest form of uterine inflammation, 



OF THE UTERUS. 243 

we find the internal layer of the organ covered with a thin, 
opaque, or more dense product, varying in color from pale 
green to dark brown, beneath which the tissue to a greater 
or less depth is converted into a similar pulp. We some- 
times find small abscesses within the muscular tissue without 
any perceptible change in the surrounding parts ; in most 
cases, however, the structure of the muscular fibre is entirely 
destroyed. 

Jletrophlebitis. Inflammation of the venous channels 
and lymphatics of the uterus, is a very frequent cause of 
the fatal termination of cases of puerperal fever. Tonnelle 
found it present in one hundred and thirty-two cases out of 
two hundred and twenty-two. Besides the appearance of 
the vessels common to ordinary phlebitis, we find the uterus 
studded with small abscesses which may be traced to the 
vessels. The lymphatics may be primarily and coincidently 
affected, or they may be attacked separately and secondarily ; 
the former is the more frequent. They present the same vari- 
cose appearance as the veins, and are thickened and distended 
with the purulent or sanious products of the inflammation. 

Puerperal Peritonitis, is the lesion most commonly asso- 
ciated with puerperal fever. It may be confined to the 
surface of the organ, particularly to the part surrounding 
the neck, or may involve more or less entirely the whole 
sac. In the sthenic forms, the appearances presented, resem- 
ble those of ordinary peritonitis. In the low typhoid forms, 
there is a peculiar absence of congestion and redness. The 
ordinary character of the exudation, is a copious effusion of 
an aplastic character, of a dirty-yellow, greenish, or brown- 
ish hue. in which flocculent particles of lymph are found 
floating, while but small patches of a thin, non-coherent 
exudation, are observed in the peritoneal sac. The smell of 
the fluid is distinctive, differing from anything found in the 
human body in health or disease, and after having been 
once noticed, cannot fail to be recognized. 



244 PATHOLOGICAL CONDITIONS. 

Extra-uterine Pregnancy. 

This species of gestation may be considered under the 
following varieties, receiving their names according to the 
part of the passage where the ovule becomes fixed : 

1. Abdominal Pregnancy. 

2. Tubo-abdominal Pregnancy. 

3. Tubal Pregnancy. 

4. Interstitial Tubo-uterine Pregnancy. 

5. Utero-tubal Pregnancy. 

1. Abdominal Pregnancy. This includes all cases in 
which the fecundated ovule fails to engage in the tube. 
Three varieties may occur. The ovule may remain in the 
ruptured ovisac and there be developed, giving rise to an 
internal ovarian pregnancy. Should it after escaping from 
the Graafian vesicle adhere to the surface of the ovary, we 
have an external ovarian pregnancy. Finally, if the ovule, 
escaping from the ovary, fall into the peritoneal cavity, 
and there undergo development, a peritoneal pregnancy 
results.. In the last class, the points to which the ovule 
may attach itself are exceedingly numerous. The placenta 
has been found attached to the peritoneum covering the 
right or left iliac fossa, sometimes to a part of the small or 
large intestine, and sometimes to the anterior wall of the 
abdomen. 

2. Tubo-abdominal Pregnancy. This name is applied to 
those cases where the ovule having but just entered the tube, 
is arrested by an obliteration or constriction of the canal, and 
there undergoes development. The placenta is attached in 
the interior of the tube, and the foetus developed in the 
abdominal cavity, and both are surrounded by a cyst, the 
walls of which are partly made up by the walls of the 
dilated tube. This includes also what has been described as 
tubo- ovarian pregnancy. 



OK THE UTERUS. 245 

3. Tubal Pregnane}/ is the most frequent of all varieties 
of extra-uterine pregnancy. The ovule is here arrested and 
developed at some spot within the tube, between its abdom- 
inal extremity and the point where it enters the uterine 
walls. The fibres of the enormously distended tube consti- 
tute the envelope of the fcetal cyst. 

4. Interstitial Tabo-uterine Pregnancy. Here the ovule 
is arrested in that part of the tube that traverses the thick- 
ness of the uterine walls. It may remain, during its devel- 
opment, enclosed by the tube, or it may make its way 
through these and be developed within the muscular fibres 
of the womb itself. 

5. Utero-tubal Pregnancy is a very rare but possible form 
of extra-uterine pregnancy. The ovule may ingraft itself 
just at the internal orifice of the canal. " In this variety, 
the foetus is found in the abdominal cavity ; the cord leaving 
the umbilicus enters the Fallopian tube, traverses its whole 
length, and is inserted in the placenta, which is itself 
attached to the internal surface of the uterus." The tube 
has evidently been ruptured, allowing the passage of the 
foetus into the peritoneum, while the placenta remained in 
the uterus. 

In all these pregnancies, the ovule has originally its 
proper membranes, the chorion and the amnion. The 
structure of the walls of the enclosing cyst varies according 
to the species of extra-uterine pregnancy. As a general 
rule, the foetus exhibits nothing peculiar in its development. 
The most common of the numerous alterations which it may 
undergo, are putrescent dissolution of its soft parts, and the 
separation of the various pieces of its skeleton ; a complete 
drying-up or mummification ; and transformation of all its 
tissues into an osseous or cretaceous substance.* 

In the tissues of the mother, new or increased vascularity 



* See Nos. 325 and 32G, College Museum. 



246 PATHOLOGICAL CONDITIONS. 

of those parts where the ovule is attached will be noticed, 
while the womb will be found to have sympathized with the 
development of the foetus by an hypertrophy of its mucous 
membrane, which, however, does not last more than a few 
months. A gelatinous substance, a kind of thick, ropy 
mucus, is also frequently found in the neck of the uterus. 
These appearances are generally wanting in the womb, 
where the pregnancy has advanced beyond term. 

Extra-uterine pregnancy generally terminates fatally. In 
the abdominal form, the pregnancy may progress to the 
later months of gestation, when, losing its vitality, the 
foetus may decompose, producing peritonitis and death, or 
it may become encapsulated and gradually absorbed ; or by 
the ulcerative process, the remains may be discharged into 
the intestinal canal, or through the abdominal walls. Where 
the case has been diagnosed before death, the dead foetus 
has been successfully removed by abdominal section. 

In the varieties of tubal pregnancy, rupture of the tube, 
and death from haemorrhage usually takes place in the. early 
months, as in the following case : 

Case. — Tubal Pregnancy, with Rupture of the Fallopian Tube — 
Hozmorrhage and Death. 

Mrs. C , aged thirty-three years, four years married, but child- 
less, had been indisposed for two weeks. Early in the morning of 
July 9th, she was taken with severe pain in the lower abdomen, 
nausea and vomiting, rapid prostration, increasing tumidity of the 
abdomen, and death at 7 o'clock P. M. 

Thirty-six hours after death, assisted by the attending physicians, 
Drs. H. J- Sartain and E. Calvin, I made a post-mortem examination. 
" A quart of bloody serum was sponged out of the abdominal cavity, 
then a pint and a-half of black coagula was removed, when the pelvic 
viscera were exposed. The right Fallopian tube was found enlarged 
and ruptured, within an inch of its connection with the uterus. The 
ovule had lodged in the tube, about half an inch from its outlet, and 
there formed its attachments. The oozing blood from the ruptured 
arterioles and venules of the tube, had destroyed the outline of the 



OF THE OVARIES. 247 

embryo, leaving a sort of granular debris lying in the fragments of the 
membranes, which were detached from the inner surface of the tube. 
The nidus measured externally about an inch in length, and three- 
quarters of an inch in transverse diameter. The walls of the uterus 
were slightly softened, and the decidua had formed."* 



Section III. THE OVARIES AND FALLOPIAN TUBES. 

[Notice ! 1. External Characters of ovaries ; size ; color ; con- 
sistence; soft and boggy, or firm and hard; surface smooth, or rough, 
irregular and fissured ; cysts beneath the surface, or projecting from 
same. Characters on section — color, density; condition of stroma, 
consistence, etc. Corpora lutea : number, size, situation; cysts; tu- 
mors; abscesses; tubercles; cancer, etc. 2. Fallopian tubes — absent 
or malformed; length; size of canal; thickness of walls; condition of 
fimbriated extremity ; tumors, tubercle, cancer, etc.] 

1. The Ovaries. 

Malformations and Malpositions. The absence or 
arrest of development of one or both ovaries is occasionally 
met with. 

The ovaries may be found in the labia majora as a con- 
genital defect, or in the inguinal or crural canal, or in the 
foramen ovale, as congenital or acquired hernise. 

Inflammation is but rarely met with in post-mortem 
examinations in an isolated form. It generally is associ- 
ated with affections of the uterus or its appendages, in 
connection with the puerperal condition. It does, however, 
occur as an idiopathic disease, and then generally attacks 
but one ovary. In the congestive stage there is more or 
less engorgement with blood, even amounting to extravasa- 
tion, enlargement and softening of the organ. 

Abscesses. As a result of acute inflammation, abscesses 



* See No. 1476, College Museum. 



248 PATHOLOGICAL CONDITIONS. 

may form in the substance of the ovary. These may reach 
considerable size, and may burst into the peritoneal cavity, 
resulting in death ; or they may discharge into the rectum, 
vagina or bladder, and end in recovery. 



Morbid Growths. 

Ovarian Tumors or Ovarian Dropsy, are generic terms 
for a class of affections characterized by the formation of 
cysts, which have a tendency to excessive development. 
The disease affects married females more frequently than 
the single, and the age from thirty to forty years is that most 
subject to it. According to statistics, the right ovary is 
more frequently the seat of the malady. Various forms of 
the disease are met with. The cysts may be simple or 
unilocular, compound or mul til ocular, or cancerous. 

Simple cysts have but a single, undivided cavity, containing 
fluid, and enclosed within the ovary or external to it. We 
may find one or more, varying greatly in size, some being no 
larger than a pin's head or pea, while others contain several 
gallons of fluid. The contained fluid also, presents great 
varieties ; it may be clear, straw-colored, highly albuminous, 
or present a viscid, glairy, more or less opaque character ; 
or we may find it of a coffee color, or greenish, with a large 
quantity of oily matter floating on the surface. In the latter 
cases the appearance is due, as shown by the microscope, to 
the presence of blood corpuscles and cholesterine plates. 

These simple cysts may acquire an enormous size, filling 
the abdominal cavity, and crowding the viscera from their 
position. In a case examined for Dr. B. Berens, in 1855, 
a free incision was made through what appeared to be the 
abdominal walls alone, when the cavity was found filled 
with a straw-colored, slightly gelatinous fluid, of which 
several gallons were removed. 

Upon extending the incisions and looking into the cavity, 



OF THE OVARIES. 249 

it presented the appearance of an entire absence of all the 
abdominal viscera ; the spinal column projected at the pos- 
terior portion, while above was seen what appeared to be the 
concave, under-surface of the diaphragm, with no trace of 
liver, stomach, or other viscus. A careful examination of 
the edp-es of the incision disclosed the divided walls of the 
cyst, closely adhered to the abdominal parietes at all points. 
With a little care, these were gradually torn away, when, 
behind the tumor, was found the atrophied viscera, crowded 
and displaced upwards and backward into the smallest pos- 
sible space. 

Pilo-eystie or Dermoid cysts may be found containing 
hair and fatty matters. These appear, in many cases, to 
be the remains of blighted ova enclosed in the body. They 
are congenital in their origin, and usually contain somefcetal 
debris, such as portions of bone, teeth, etc. 

Case. — Ovarian Cystic Disease — -fatal termination. Autopsy revealing 
presence of hone and teeth in small cyst. 

The following interesting case occurred in the practice of Dr. William 
A. Read, of this city, from whom the appended statement has been 
received : 

Miss , aged 42 years, after having been treated by several physi- 
cians, came under the care of Dr. Read for the treatment of what was 
diagnosed as an ovarian tumor. Paracentisis was resorted to, with the 
result of drawing off a considerable quantity of gelatinous fluid, but 
without any permanent benefit. The disease pursued the usual course, 
and the patient finally died of exhaustion. 

The autopsy revealed a large multilocular tumor, filling a large 
portion of the abdominal cavity. Upon removing the same from its 
pelvic attachments, and opening one of the smaller cysts within the 
broad ligament, the latter was found filled with a quantity of highly 
offensive fluid, and containing one large, irregular mass of bone, in which 
were imbedded two well-formed teeth, a smaller piece with one tooth, 
and nine detached teeth found in the same sac, making twelve in all.* 

The first impression upon the discovery of such remains would natu- 

* See Nos. 1340 and 1341, College Museum. 



250 PATHOLOGICAL CONDITIONS. 

rally be, that the case was one of extra-uterine pregnancy ; but in this 
instance, the well known character of the lady was such as to preclude 
such a theory ; while the presence of the unbroken hymen was further 
evidence of virginity. From the impossibility of conception having 
been the source of the bony and dental remains found in this and simi- 
lar cases, the problem can only be solved, by supposing that, two ova 
had been impregnated when this woman was conceived, one of which, 
in some manner, became imbedded within the other, so that at her 
birth this lady had within her abdomen the remains of her undeveloped 
twin. These became encapsulated within the pelvis, and finally in- 
duced the local disease, which resulted in death. 

That this is the correct explanation of such cases, is confirmed by the 
fact that similar remains have been found within the bodies of males. 

Multilocular cysts disclose, instead of a single cavity, 
numerous chambers, containing secondary, and even tertiary 
cystic growths, either sessile or pedunculated, and with 
varying contents. 

By the complicated form, we understand that in which, to 
some other diseased state of the organ — as hypertrophy, 
fibrous tumors, or carcinomatous growths — the cyst forma- 
tion is superadded. 

Fibrous groivths. These are developed in the tissue of 
the ovary, and present a globular form, with well defined 
outline. They may attain an enormous size ; the largest one 
on record, occurred in the practice of Dr. Simpson, and 
weighed fifty-six pounds. We occasionally meet with proofs 
of a tendency to so-called ossification, in the presence of cal- 
careous matter, into which a portion of the tissue has been 
converted. 

Malignant disease of the ovary, is by no means a rare 
affection. It is generally limited to one side, and appears 
as scirrhus, encephaloid, hsematoid, melanotic, or alveolar 
cancer, either as an isolated growth, or in the infiltrated 
form, and generally as an addition to some other morbid 
formation. It runs a rapid course, although it has been 
met with even before puberty; forty-one years was the 



OF THE FALLOPIAN TUBES. 251 

average age at death according to the statistics collected hy 
Dr. Walshe. 

Cartilaginous tumors are extremely rare in the ovaries. 

Tubercles are occasionally found as small, cheesy deposits. 



2. The Fallopian Tubes. 

Congenital Anomalies. One or both of the tubes 
may be imperfectly developed, in connection with an unsy in- 
metrical development or total absence of the uterus. The 
tubes may be occluded by the closure of one or both ends, 
and the point of insertion into the uterus may be abnormal. 

Inflammation. Catarrhal inflammation is of not un- 
frequent occurrence, and may lead to partial or total, tem- 
porary or permanent closure of the channel of the tubes. 
Thus the fimbriated extremities may become agglutinated 
to the ovaries, the broad ligament, or the uterus itself; or 
obliteration may occur at one or more points within the 
passage. 

The continued accumulation of the secretion of the 
mucous membrane will cause distension, either simulating 
a cyst formation, or presenting the appearance of several 
saccular dilatations. The dilatations, containing mucus 
matter of a more or less purulent character, or fluid of 
an heterogeneous constitution, are rarely of large size, 
although an instance is on record in which the distension 
amounted to five inches in diameter. The morbid contents 
may be poured into the uterus, or in less favorable cases the 
sac is ruptured, and the contents are effused into the ab- 
dominal cavity. 

Morbid Growths. 

Cysts of small size frequently affect the fimbriated ex- 
tremities of the tubes. 



252 PATHOLOGICAL CONDITIONS. 

We may also find fibroid growths, carcinoma and tubercle; 
the two latter commonly, although not invariably, secondary 
to similar diseases of the uterus. 



Section HE. OF THE MAMM-E3. 

[Notice: 1. External Characters — abnormalities; silvery lines on 
integument, indicating previous enlargement; sinuses; firm, or soft and 
flabby. Nipple — its size, color, retracted ? ulcers ; excoriations, etc. 
Areola — size and color. 2. Appearance on section — color of substance ; 
consistence of gland and fluids exuding; abscesses; tumors; cysts; 
cancer, etc.] 

Anomalies. Supernumerary mammae, with the power 
of secreting milk daring lactation, have been observed in a 
number of instances. 

The cases of absence of one or both mammae are rather to 
be classed as the result of arrest of development or atrophy. 

A too early development of the glands in young children 
is occasionally met with, where there is a precocious de- 
velopment of the organs of generation. 

While the mammary glands in the male usually remain 
in a rudimentary state during life, cases have occurred 
where they have acquired an increased size, and have been 
stimulated to such a functional activity as to permit of the 
suckling of an infant. 

Hypertrophy and Atrophy. When puberty occurs, 
the breasts naturally enlarge and often become tender ; and 
such a temporary enlargement very commonly accompanies 
menstruation. 

An increase of size, such as normally takes place during 
pregnancy, between the fourth and ninth months, will occa- 
sionally commence at puberty, and go on until the organ 
attains an enormous size. In some cases the breast has 
been found, after death, to weigh as much as twenty pounds, 
the tissue being perfectly normal. 



OF THE MAMMAE. 253 

Both breasts are usually affected, although one is com- 
monly more so than the other. 

After the cessation of the menses, the breasts normally 
begin to atrophy. 

We may also have an atrophy of the breast following 
upon lobular hypertrophy, as described by Sir A. Cooper. 

Inflammation and Abscess. Inflammation of the 
Nipple and Areola, preceding or following a fissured state 
of the nipple, usually occurs at an early period of lactation, 
and especially with the first child. Abscess of the areola is 
often a consequence. 

Inflammation of the Breast, generally terminating in sup- 
puration, may occur in three positions : either in the subcu- 
taneous areolar tissue, supramammary abscess; or in the 
areolar tissue, in which the gland is imbedded, submammary 
abscess ; or in the gland itself, mammary abscess. 

Chronic Abscess of the Breast may be of two kinds : the 
diffused and the circumscribed or encysted. The former 
may occur at all ages, and in the single as well as in the 
married. Tt usually appears in the submammary areolar 
tissue, and may acquire a very large size ; and by pushing 
the mammary gland before it, gives the breast a pointed, 
conical shape. 

Chronic encysted abscess, so closely simulates vari- 
ous tumors in this situation, as to render a diagnosis in 
some cases very difficult during life. It usually com- 
mences as a result of pregnancy ; sometimes as a conse- 
quence of lacteal inflammation ; but usually without any 
injury or other direct local cause. An indolent, indurated 
swelling forms, and this may gradually soften in the centre, 
although fluctuation may for a long time be very indistinct, 
and even absent, ow T ing to the thick wall of plastic matter 
that is thrown around the collection of pus. It is not unfre- 
quently attended with retraction of the nipple. 



254 PATHOLOGICAL CONDITIONS. 

Syphilitic ulcers are also found affecting the nipple ; while 
eczematous and erysipelatous inflammation in this situation 
are of frequent occurrence. 



Morbid Growths. 

The mammae are frequently the seat of adventitious 
growths, presenting the characters of non-malignant and 
malignant formations. The most common of the benig- 
nant tumors is, perhaps, the 

Adenoid Tumor or Adenocele. This is most fre- 
quently met with in young women under thirty years of age, 
seldom commencing at a later period than forty. It may 
remain stationary for years, or it may slowly increase or grow 
very rapidly to a great size. It has frequently been mistaken 
for cancer, but the otherwise good health of the patient, the 
mobility of the mass, the absence of all implication of the 
skin or glands, the want of hardness and its circumscribed 
character, are points of diagnostic value. 

On removal, it appears irregularly lobulated, is encapsu- 
lated, and its cut surface has a bluish or grayish-white color, 
which, on exposure to the air, assumes a rosy tint. On 
pressure, drops of thick, creamy fluid will often exude. Ac- 
cording to Birkett, the microscope shows it to consist of 
imperfectly developed hypertrophy of the glandular tissue, 
the terminal cells of which are filled with epithelial scales. 
This tumor sometimes simulates malignant disease by its 
extreme rapidity of growth, especially where it developes 
later in life. It then, after section, presents a lobulated, 
glistening appearance, somewhat resembling a mass of rice 
or sago jelly, often having cysts interspersed throughout its 
substance containing fluid or semi-solid glandular tissue. 

In rare cases, the adenocele may return, even after extir- 
pation of the entire mammary gland. 



OF THE MAMM.E. 255 

Cystic Tumors. These may occur as the unilocular 
cyst, or as the eysto-sarcomatous tutaor. 

Unilocular cysts usually occur as a small, thin sac, of about 
the size of a filbert, containing a clear, serous fluid, imbedded 
in the glandular structure of the breast, and movable under 
the skin. As they increase in size or become multiple, their 
contents may assume a greenish-brown or blackish tinge 
from effused blood. According to Brodie, they are originally 
formed by a dilatation of the lactiferous tubes. 

Unilocular cysts occasionally attain an immense size at the 
same time that their walls remain thin and supple. In some 
of these instances, the fluid continues to the last, of a truly 
serous character ; while in others, it becomes more or less 
glairy or mucilaginous. 

Sometimes the walls of the cysts have been found to have 
undero-one calcareous defeneration. 

The cysto- sarcoma, occurs as an isolated, globular or oval, 
and more or less movable cyst ; or there are numerous 
growths of this kind, varying in size from a pin's head to a 
hen's egg. The inner surface is smooth, or it presents a 
broad-based, tabulated, cauliflower growth or warty excres- 
cences, and the substance of the surrounding gland is indu- 
rated and atrophied. A retraction of the nipple may also be 
observed. A transverse section shows a double sheath : one 
proper to the cyst, and the other the result of condensation 
of the adjoining textures. The contents are either fluid, of a 
limpid, opalescent, non-albuminous, or a grumous, brownish, 
highly albuminous character ; or solid, approaching the char- 
acter of a fibroid deposit, composed of a pale, compact sub- 
stance, traversed by undulating fibrous lines, which imper- 
fectly divide it into lobes of various sizes and shapes. 

Hydatid cysts, containing the echinococus, occur in the 
female breast. The tumor is firm to the touch, and contains 
a clear fluid, in which the microscope detects the tenacula ol 



256 PATHOLOGICAL CONDITIONS. 

the echinococns, the animalculum itself being attached to the 
internal wall of the cavity. 

Fibrous, cartilaginous and osseous tumors, are of doubtful 
or very rare occurrence. 

Carcinoma. Cancer affects the mammae more frequently 
than any other organ of the body. The age from forty to 
fifty years seems most liable to its occurrence. According to 
Dr. Walshe, the left side is more frequently affected than 
the right, and both are but rarely involved. 

All varieties of carcinoma have been met with in the 
breast ; but scirrhus is by far the most frequent form in 
which it occurs primarily. The encephaloid variety is 
generally engrafted upon the scirrhus, although it may also 
be primary. The colloid form is the most rare. 

/Scirrhus appears as a hard, lobulated tumor, imbedded in 
the adipose tissue of the gland, causing adhesion to the skin 
and retraction of the nipple. Although at first movable, it 
soon becomes firmly adherent to the subadjacent parts, and 
involves more or less the gland-tissue, the muscles of the 
thorax, and the adjoining glands. Instead of an isolated 
tumor, there may be an infiltration of the various structures 
of the part from the commencement. It will then have an 
ill-defined outline, sending out branches into the adjacent tis- 
sues, and involving in its mass the lacteal tubes and lym- 
phatics. These become contracted and flattened into many 
bands, giving a peculiar appearance to this form of mam- 
mary cancer not observed in any other. 

Ulceration of the skin gradually follows near the nipple ; 
the edges of the sore are raised, everted and puckered. The 
surface is of a bluish-red color. A purulent, ichorous fluid, 
of a faint, fetid odor, is secreted ; haemorrhage may ensue, 
and the patient sinks from exhaustion. 

The average time occupied by a scirrhus in reaching its 
full development is from two to three years. When the 



OF THE MAMM.E. 257 

ulcerative stage has once begun, the system is soon broken, 
and the disease proves fatal in from six months to two years. 
The older the individual is at the first appearance of 
Bcirrhus, the more slowly does it pass through the various 
stages of its growth. 

The axillary lympathic glands are also in most cases found 
swollen, hard, and infiltrated with cancerous matter. 

The pectoral muscles, ribs and costal cartilages are also 
found more or less involved; and a secondary affection of 
the pleura and lung is not unfrequent. We may also look 
for oedema of the extremity on the affected side, caused 
towards the termination of the disease by direct interference 
with the venous circulation. 

The encephaloid form occurs earlier in life, and commonly 
runs a more rapid course. Its margin is less defined, the 
base of the tumor being diffused among the healthy cellular 
membrane, or other parts where it may be situated. It 
differs from scirrhus also in this : that the disease may ad- 
vance to ulceration without any affection of the glands of 
the axilla. 

The Male Mammas. 

The structure of the male mammaB resembles that of the 
female gland, though in a rudimentary state ; hence we may 
find anomalies and morbid conditions in them similar to 
those found in the latter. 

An increased number of mammae have been met with. 

Hypertrophy sometimes occurs. 

There have been well authenticated instances of the secre- 
tion of milk by men. 

The male breast may be the seat of non-malignant and 
malignant growths. Cancers, simple cysts, compound cysts, 
and other tumors occur, but exceptionally. 

17 



PART IV. 



MISCELLANEOUS SUBJECTS. 



CHAPTER I. 
OF THE PERIOSTEUM AND BONES. 

Section I. OF THE PERIOSTEUM. 

[Notice : degree of vascularity ; thickness ; density ; detached or 
adhered ; effusions beneath ; serum or pus ; ulcerative destruction of ; 
condition of bone beneath, etc.] 

Inflammation of the periosteum occurs in the vicinity 
of chronic ulcers ; as essential to the reproduction of bone 
after fractures ; in consequence of syphilis or its mercurial 
treatment; in rheumatism; and as a manifestation of a scrof- 
ulous cachexia. 

In incipient inflammation, the membrane has a reddish 
tinge, a humid, succulent appearance, and there is more or 
less of a serous effusion, causing a slight separation from the 
bone. As the inflammation advances, the connection be- 
tween the membrane and the bone becomes more lax, and 
the effusion assumes a purulent character. 

Syphilitic inflammation of the periosteum is apt to appear 
in detached spots, causing swelling, induration, the formation 
of new osseous matter and necrosis. The periosteum of the 
skull, sternum and tibia are most frequently attacked. 

A malignant disease of the periosteum, the ^consequence 
of long-continued or repeated attacks of inflammation, is 
described by Stanley, It occurs on the bones of the hips, 
(258) 



OF THE BONES. 259 

and gives rise to the growth of a fungous excrescence upon 
the membrane. " This is sometimes soft and flocculent on its 
surface, with a firm, grayish, gelatinous base; at others it 
consists throughout of a firm, gelatinous substance." 



Section H. OF THE BONES. 

[Notice : 1. Surface of bone — smooth or rough, firm and hard or 
soft; periosteum present or destroyed; caries; necrosis; tumors, etc. 
2. Whole bone — weight and size increased, ' or diminished? bent or 
fractured? 3. Appearance on section — density of different portions ; 
condition of cancellated portion ; destroyed, or softened ; abscesses ; 
caries; necrosis; tumors, etc. 4. Medulla — density, color, vascularity, 
morbid growths.] 



Inflammation and Abscess. Acute inflammation 
rarely takes place except in connection with mechanical 
injury. 

Inflammatory processes in bone, give rise for the most 
part, to an increase of medullary tissue, and to softening of 
the osseous structure. Haversian canals and medullary 
spaces increase in size, and ultimately become confluent by 
the gradual absorption of the surrounding osseous lamellae. 
The results of progressive inflammation are congestion, exu- 
dation, suppuration, caries and necrosis. An enlargement 
of the affected portion is invariably met with. 

In case the exudation be absorbed, or the inflammatory 
process be arrested, the parts may return to their normal 
condition, or the bone retains a permanently disorganized 
condition, which may present either an increased condensa- 
tion and induration, as in gouty bone, or an abnormal rare- 
faction of the bone, as in the bones of rickety individuals. 

The same state of rarefaction, or osteoporosis, according 
to Lobstein, is occasionally met with in advanced life, as 
an effect of mal-nutrition. 

Sicpjjuration, with the formation of abscess, may be dif- 



260 PATHOLOGICAL CONDITIONS. 

fused or circumscribed. In circumscribed abscess, we find 
a cavity generally in or near the epiphyses, lined with a 
vascular membrane, and thickening of the adjoining peri- 
osteum, and of the surrounding cellular tissue. 

Caries. Caries, a process of molecular disintegration, 
may occur in all bones, and in every part of their structure, 
though it generally affects the cancellous tissue. The 
carious bone is porous and fragile, of a gray, brown, or 
blackish color, partly, broken down in softened masses, and 
partly hollowed out into cells, which contain a reddish- 
brown and oily fluid. Small portions of dead bone lie 
detached in the carious cavity. The periosteal and medul- 
lary membranes, and the bone around the carious portion, 
will be found extremely vascular, and in many cases, 
compact masses of osseous tissue are deposited around the 
carious cavity. 

Caries of bone occurs as a result of inflammation, and 
corresponds to ulceration of the soft tissues. It frequently 
results from chronic suppurative arthritis, when, from de- 
struction of the articular cartilages, the disease attacks the 
cancellated structure of the extremity of the bone. 

Necrosis. The death of a portion of osseous tissue, or 
necrosis, although frequently accompanied with caries, is 
entirely distinct from it. It attacks principally the com- 
pact tissue, and is met with, therefore, most frequently in 
the shafts of long bones. The necrosed portion is of a 
dirty, yellowish-white color, and has a dull, opaque look ; 
after exposure to the air, it gradually becomes of a green, 
deep brown, or black tint. Its boundaries are usually dis- 
tinct, but sometimes are so imperceptibly lost in the healthy 
tissue, that it becomes difficult in the dead body to deter- 
mine its exact limits. 

Necrosis results from causes which interfere with the nu- 



OF THE BONES. 261 

trition of bono, as from suppurative periostitis, traumatic 
destruction of the periosteum, or osteitis. Ulcerative de- 
struction of the surrounding soft parts, or the diminished 
vitality attending certain general diseases, as typhus, etc., 
may also result in necrosis. 

The death of a portion of bone is followed by inflammation 
at the dividing line, which finally results in the separation 
of the dead portion or sequestrum. This change is soon 
followed by the production of new bone, in which process 
the periosteum and medulla may take part. 

Rachitis or Rickets, is essentially a disease of mal- 
nutrition, most frequently affecting children between the 
first and third years, although it does also occasionally 
occur later. The lower extremities are the first to show the 
effects of the disease, by a curvature commonly referred to 
too early attempts at walking. A contortion of the bones of 
the pelvis, of the spine, the thorax, the upper extremities, 
and malformations of the skull, may follow in the course of 
the disease. 

The bone on analysis, shows a decided diminution in the 
quantity of phosphate of lime, and a uniform increase of 
fatty matter ; fluoride of calcium always present in healthy 
born, is also wanting. 

The joints are usually swollen, and the epiphyses of the 
bones enlarged by the exudation of a reddish kerum into 
the enlarged cancelli and canals, the osseous corpuscles, at 
the same time, showing a deficiency or entire absence of 
earthy matter. The periosteum is pulpy and thickened, 
and more than usually adherent to the bone. 

If a reparative process have been set up, the deformity 
may have been greatly diminished, or even entirely re- 
moved ; or a new deposit of bone taken place, so as to 
afford a useful limb during life. " This supplementary ossifi- 
cation is found, on vertical section of a long bone, chiefly on 



262 PATHOLOGICAL CONDITIONS. 

the concave side, so that this part of the shaft may present 
double and treble the thickness of the opposite side. The 
structure, at the same time, is very dense, and of ivory 
texture." 

In flat bones, as in those of the skull — which is commonly 
unduly large in rickety subjects — there is a uniform thicken- 
ing. In some cases the thickening affects the capacity of 
the foramina. 

In a peculiar form of disease of the cranium described by 
Elsasser, the bone is atrophied, soft and porous ; numerous 
openings are found along the lambdoidal suture, and in the 
body of the bone, with the exception of the occipital pro- 
tuberance. The perforations are filled up only by the dura 
mater and pericranium, which are adherent to one another. 
This disease is commonly met with between the third and 
sixth months of infant life. 

Mollities Ossium, or Osteomalacia, is regarded by 
some as a form of atrophy, by others as identical with 
rachitis, except that it attacks adults instead of children, 
and by others as an essentially distinct osseous disease. 

It is of rare occurrence, and consists in perverted nutri- 
tion of the skeleton, whereby the earthy phosphates are 
eliminated from the system by the kidneys, while a deposit 
of fat takes place in the cartilaginous matrix. 

As the bones of the trunk are especially liable to be 
attacked, the individual affected becomes reduced in size by 
the collapse of the vertebral column. 

It attacks females more frequently than males, and the 
former chiefly after they have commenced child-bearing. 

The disease presents two varieties — the waxy, in which 
the bones, especially those of the pelvis, present a dirty, 
dark-yellow color, and remain greasy after drying ; and the 
fragile, where the bones are of a snowy whiteness, and of 



OF THE BONES. 263 

a light, transparent, open texture, and so fragile that they 
give way under the mere pressure of the finger. 

Under the microscope, we find the corpuscles and their 
eanaliculi empty and transparent, and only faintly visible, 
and the Haversian canals unnaturally enlarged. 

Morbid Growths. 

Enchondromatous Tumors, are usually found in 
connection with some of the short bones, more particularly 
those of the fingers and toes, though the ribs, vertebrae, 
sternum, tibia and femur are sometimes attacked. 

They may originate on the surface of the bone, or within 
the cancellous tissue. In the former case, they exhibit a 
tabulated arrangement, and are surrounded by a fibrous 
sheath ; in the latter, the bone gradually expands with the 
development of the tumor. The rapidity and extent of 
their growth vary. In their microscopic characters, the 
enchondroma resembles normal cartilage. 

The central variety presents a semi-elastic feel, and, on 
section, the knife passes through a thin, crackling shell of 
bone, and then exhibits a white, cartilaginous mass, which is 
occasionally found to contain some small cells ; while in 
some tumors there is an interlacement of fibrous tissue, in 
which cartilage is imbedded. 

The superficial variety is microscopically and chemically 
identical with the central form, but has no osseous shell. It 
is met with chiefly in the pelvis, on the cranium, and on the 
ribs. 

There may be a partial ossification. 

The disease is chiefly met with in early life. 

Osseous Growths, consisting of true bone, are divided 
into exostoses and osteophytes. The surface of the former is 
smooth ; their outline generally a segment of a circle or of 



264 PATHOLOGICAL CONDITIONS. 

an ellipse ; their cause : an idiosyncracy of the individual, 
not referable to any definite constitutional taint. Of the 
latter, the surface is rough ; they do not form any well- 
defined local, circumscribed tumor ; are referable to rheu- 
matic or gouty inflammation, to syphilis or other causes. 

Exostoses are of two kinds : the one, hard and compact ; 
the other, softer and more spongy. The hard or ivory ex- 
ostosis is extremely dense, and whiter than the bone from 
which it springs, but possesses a true bony structure. It 
generally grows from flat bones, and is of small size. It has 
been known to necrose and to slough away from the parts 
on which it has been situated. 

Spongy exostoses often attain a considerable size, and are 
very commonly multiple. They differ from the compact 
variety in being composed of cancelli, containing medullary 
matter, and surrounded by a shell of bone. They spring 
from the cancellous, or compact tissue of the bone, and their 
surface is continuous with that of the latter. In some cases 
the cavity of the exostosis communicates directly, or is con- 
tinuous, with the medullary cavity of the bone. Their most 
common seats are the tibia, fibula and humerus. 

The osteophyte chiefly affects the more vascular portions 
of bones, as their articular ends, their rough lines, or, in the 
skull, the sutural cartilages ; being generally the product of 
an inflammatory process in the superficial part of the bone, 
and in the periosteum. 

Fibrous Growths always develop in the . cancellous 
structure. All the long bones and many of the flat bones 
are liable to this disease. They present more or less elas- 
ticity, are of a gray and opaque appearance, and yield gelatin 
on boiling. They may attain an enormous size. 

Cystic Tumors are of rare occurrence, and are generally 
met with in adults. 



OF THE BONES. 265 

They may be unilocular, usually filled with a solid mass 
of a fibro-cellular or fibro-cartilaginous character ; or mul- 
tilocular, with thin and serous, sero-sanguinolent, viscid or 
dark-colored contents, often associated with central, fibrous 
growths. 

Hydatid cysts have been met with. According to Stan- 
ley, both the acephalocyst and the cysticercus cellulosse 
have been found, but more frequently the former. 

Tubercles are occasionally present in bone, as the 
yellow, opaque tubercles, deposited chiefly in the spongy 
bones and the cancellous portions of long bones. They may 
soften or become cretified. 

Vascular Tumors are of not very frequent occurrence. 
They are met with most commonly in the cancellous artic- 
ular ends of the long bones ; although they have also 
been found in the pelvic bones, the bones of the skull, and 
in the ribs. 

In the most frequent class of cases, a new tissue is de- 
veloped in the osseous structure, and the tumor partakes of 
an encephaloid character. A creamy, curdy or brain-like, 
soft, and very vascular mass, is formed as the essential con- 
stituent. This will be found to present every shade of tran- 
sition, from a purely vascular tissue, of an erectile character, 
to true encephaloid cancer. 

In a second, more rare form of disease, there is developed 
in the bone a vascular, erectile growth, closely resembling 
capillary naevus in its structure, composed of an infinity of 
blood-vessels, interlacing in every possible way, so as to 
form a soft, reddish-yellow tumor. 

In a third form, a hollow cavity is formed in the bone, 
scooped out of the cancellous structure and filled with blood, 
partly liquid and partly coagulated, and having arterial 
branches freely opening into it. According to the stage of 



266 PATHOLOGICAL CONDITIONS. 

the disease, the blood is found in cells, intersected by fibres, 
or laminae and fibres, the remains of the original osseous 
structure ; or in a more advanced stage, in a single cavity. 
The shell of bone surrounding the cavity is very thin and 
expanded, being usually absorbed at one point, where it 
often becomes at last perforated. This last class constitutes 
true aneurism of bone. 

Oephalohcematoma, met with in infancy on the cranial 
bones, as a result of pressure during parturition, is an effusion 
of blood between the pericranium and the bone, commonly 
occurring on one of the parietal bones, most frequently on 
the right side. Rare cases of internal cephalhematoma 
have been recorded in which the effusion took place between 
the dura mater and the bones. 

Cancer of bone most frequently occurs in the head of 
the tibia and the lower end of the thigh bone, occasionally 
in the humerus and in the jaws, more especially about the 
antrum. 

The encephaloid variety is the most frequent. It is of 
two distinct forms : in the one, the morbid growth is central, 
springing from the medullary canal; in the other, it is 
peripheral, being attached to the compact osseous substance. 

In the central form, it is usually situated at or about the 
articular ends, but always affects the Avhole of the bone by 
infiltration. 

In the peripheral, the more common form of cancer of 
the bone, the osseous tissue is not so completely invaded ; 
for although the disease may be located upon, or in intimate 
contact with the outer layers of the bone, which are incor- 
porated in it, it does not extend into the cancellous tissue or 
the medullary canal. In this form, the muscles attached to 
the affected portion of bone will often be found extensively 
infiltrated with cancer-cells. 

Encephaloid of bone is harder and more fibrous looking 



OF THE MEDULLA. 267 

than the same affection elsewhere. The cancer-cell also is 
not so well marked, and may indeed be absent altogether. 
Occasionally some colloid, and more rarely melanotic mat- 
ter, is intermixed, but scirrhus is never found in bone. 



Of the Medulla. 

11 It is yet to be determined in how far the medulla is 
liable to be primarily affected. It varies in consistency ac- 
cording to the vigor of the individual ; while in dropsical 
and phthisical cases we find it thin and serous, or yellow in 
icterus, or very scanty in ivory condensation of a bone. It 
exhibits greater firmness, and a richer pink hue, in habits 
tending to an inflammatory character. The real seat of 
inflammation in bone is the membrane that lines its cavi- 
ties. It is, therefore, fair to infer that, in all diseases depend- 
ent upon the state of the vascular system, whether of an 
ordinary or of a malignant character, the medulla is affected 
coincidently with, if not previously to, the bony tissue 
itself." 

Morbid growths, of various kinds, may be found within 
the medulla. 

The Cysticercus cellulose, and Echinococus, are said to 
have been detected within the medulla and periosteum. 



268 PATHOLOGICAL CONDITIONS. 

CHAPTER II. 
DISEASES OF THE JOINTS. 

. Malformations. Cases of congenital anchylosis, the 
joints being absent, have been met with ; also imperfectly 
developed joints, with a partial or total absence of the liga- 
ments. Supernumerary joints also occur, either with the 
normal, or with an excessive number of bones. 

Morbid Conditions of the Synovial Membrane. 

Inflammation may be acute, subacute or chronic. It usually 
results from exposure to cold, especially in rheumatic or 
syphilitic constitutions. 

There is at first a congestion and increased vascularity of 
the membrane, and a loss of its satiny polish ; the synovia 
is increased in quantity, but becomes thin and serous, and 
at a later period, mixed with plastic material. If the dis- 
ease progress, the vascularity and swelling of the membrane 
increase, and it becomes turgid and distended with blood 
and effused fluids ; a thin, purulent-looking fluid, composed 
of granular corpuscles, floating in a serous liquid, is poured 
out, and disintegration, with thinning and erosion of the 
cartilage, ensues ; or granulations are thrown out on the 
looser portions of the membrane, and, becoming injected with 
blood-vessels, form fringed membranous expansions, in con- 
tact with the ulcerating part of the cartilage. 

In chronic synovitis, the swelling from the accumulated 
serous fluid may become so considerable as to constitute a 
true dropsy of the joints — hydrarthrosis. This same accu- 
mulation may, however, take place without any evidence of 
preceding inflammation. 

Pidjjy Degeneration of the Synovial Membrane is peculiar 
to the articular lining membranes, nothing analogous having 






OF THE JOINTS. 269 

been found in the serous sacs. The reflected portions of the 
synovial membrane are first attacked, and converted into a 
light-brown, pulpy substance, from a quarter to a half, or 
even a whole inch in thickness, intersected with white mem- 
branous lines and red spots, formed by small injected vessels. 
The membrane of the cartilages are then invaded, ulceration 
in the cartilages going on at same time, till the ulcerating 
surfaces of the bone are exposed. 

The disease almost always occurs before the middle period 
of life, frequently can be traced to no cause, but is occa- 
sionally the consequence of repeated attacks of inflammation. 
It generally occurs in the knee, but has been met with in 
the ankle and in a joint of the finger. 

A growth of large villous processes, presenting a shaggy 
appearance, is sometimes observed. " They have sometimes 
the form of simple threads or flattened shreds, or their free 
extremities are split into filaments or have a club shape, or 
resemble melon-seeds hanging singly, or in clusters from 
each stalk. In many cases, the healthy texture of the 
articulation is not materially affected." 

Morbid Conditions of Bursae. "These small syno- 
vial sacs are liable to be affected much in the same way as 
larger ones. They may be attacked by inflammation more 
or less acute or quite chronic, resulting from rheumatism, the 
abuse of mercury, or some other constitutional affection ; or 
excited by violence or long-continued pressure. The effusion 
which takes place may, in cases of a chronic kind, be a sim- 
ple synovial or serous fluid ; but when the inflammation is 
more acute, it is either a turbid serum, with flakes of fibrin- 
ous matter floating in it, or actual pus." The walls of an 
inflamed bursa sometimes become very much thickened by 
the organization of layers of fibrinous effusion. 

In cases of long-standing inflammation, flat oval bodies, 
resembling melon-seeds, of a light-brown color, are not unfre- 



270 PATHOLOGICAL CONDITIONS. 

quently met with. Their origin is no doubt to be traced to 
the coagulated lymph effused in the beginning of the disease. 

In the synovial sheaths surrounding the flexor tendons of 
the fingers, as they pass under the annular ligament, small 
bodies, resembling grains of boiled rice, are also occasionally 
found. 

The so-called ganglions are small collections of fluid in 
bursal cavities of new formation, and occur principally on 
the back of the wrist and forearm. In the sheaths of the 
tendons of the hand, these synovial accumulations may be- 
come so excessive, as to greatly damage the usefulness of 
the member. 

Morbid Conditions of Cartilage. The thickness of 
cartilage may be greatly increased, while the tissue becomes 
soft and yielding. In advanced age, the articular cartilages 
become considerably thinned ; ossification of the cartilage 
occurs, sometimes gradually with advancing years, at 
others in connection with chronic rheumatic arthritis. In 
joints apparently not diseased, we sometimes find the 
cartilages more or less deficient at one or more points, due 
to pressure and consequent partial atrophy. Sometimes 
its place is taken by a hard, semi-transparent substance of a 
gray color, with an irregular granulated surface, the result 
of a fibrinous exudation. 

The free surface of cartilages is occasionally found covered 
with a thin layer of lithate of soda, as the result of gout. 

Loose cartilages may be found in the knee and other large 
joints ; they never contain any of the characteristic cells of 
cartilage, and appear to consist solely of compressed fibrillating 
exudation. They vary in size and number, are more or less 
oval and flattened, with a smooth surface, and are sometimes 
attached to the synovial membrane by a pedicle of varying 
length. In the latter case, they are invested by a serous cov- 
ering. Calcareous deposits are occasionally met with in them. 






OF THE JOINTS. 271 

Ulceration of Cartilage may occur as an acute or 
subacute affection. The cartilage corpuscles, instead of 
being of their usual form, will be found larger, rounded or 
oviform ; and instead of two or three nucleated cells in their 
interior, they contain a mass of them. The cavities of the 
enlarged corpuscles open on the ulcerated surface, by orifices 
of various sizes. The texture of the ulcerating cartilage, 
shows no trace of vascularity. In most cases, a vascular 
false membrane is found in opposition to the diseased part. 
The membrane generally adheres with some firmness to the 
ulcerating surface, in other instances it is loosely applied to 
it ; but in all cases the two surfaces are accurately moulded 
to each other. If a portion of the false membrane be torn 
slowly off, the cartilage will be found to be rough and 
honeycombed, and into each depression on its surface, a 
nipple-like projection of the vascular membrane will be seen 
to have penetrated. 

Chronic Rheumatic Arthritis is very frequent in the 
hip, the shoulder, the knee, and the articulations of the hand. 
The process consists essentially, first, in an hypertrophy of 
the articular cartilage, generally at the margin, and princi- 
pally near to the articular surface. Secondly, in the devel- 
opment of true osseous tissue in the hypertrophied cartilage. 
We will, therefore, find irregular enlargement of the articu- 
lating head of the bone ; an absence of the articular carti- 
lages, or new osseous growths surrounding their margins ; 
and the synovial sacs presenting evidences of having been 
the seat of chronic inflammation. 

Scrofulous Arthritis, or White Swelling, attacks pri- 
marily the articular extremities of the bones. They become 
very vascular and softened, so that they can be readily cut 
with a knife, while a characteristic transparent and afterwards 
a yellow, cheesy substance is deposited in their cancelli. As 



272 PATHOLOGICAL CONDITIONS. 

the disease advances, the cartilage ulcerates, and the osseous 
tissue gradually wastes and undergoes a true caries. Abscess 
forms in the joint, and finds its way by ulceration to the 
external surface, causing numerous and circuitous sinuses in 
the neighboring soft parts. 

In some cases, the disease may commence in the synovial 
membrane, extending finally to the cartilages and ultimately 
to the bone. 

The disease affects principally the joints of children, and 
rarely occurs after the age of thirty. The existence of scrof- 
ulous disease in other parts, and the deposition of the yellow, 
cheesy matter within the cancelli. will serve to distinguish 
this disease from simple caries, resulting from inflammation. 

Disease of the Spinal Column. The joints of the 
vertebrae are liable to nearly the same affections as more 
perfectly developed articulations. 

The scrofulous disease just described may attack the can- 
cellous tissue, causing caries and the deposition of cheesy 
matter. The first effects are generally perceptible where 
the intervertebral cartilage is connected with the bone, or in 
the intervertebral cartilage itself, although ulceration may 
commence on any part of the surface, or even in the centre 
of the bone. In some cases, of rarer occurrence, the bodies 
of the vertebrae are affected with chronic inflammation, with 
ulceration of the intervertebral cartilages as the consequence. 

If not checked, the disease proceeds to the destruction of 
the bodies of the vertebrae and of the intervertebral carti- 
lages, leaving the posterior parts of the vertebrae unaffected. 
The necessary consequence is a curvature of the spine for- 
ward, and a projection of the spinous processes posteriorly. 

Chronic inflammation of the bones sometimes extends 
to the membranes of the spinal cord ; and when the cur- 
vature is very great, the cord may be so compressed that 
it cannot properly discharge its functions." Suppuration 



OF THE JOINTS. 273 

may take place at different stages of the disease, sometimes 
earlier, sometimes later. " The soft parts in the neigh- 
borhood of the abscess become thickened and consolidated, 
forming a thick capsule, in which the abscess is sometimes 
retained for several successive years ; but from which it 
ultimately makes its way to the surface, presenting itself in 
one or another situation, according to circumstances. In the 
advanced stages of the disease, new bone is often deposited 
in irregular masses on the surface of the bodies of the neigh- 
boring vertebras ; and where recovery takes place, the cari- 
ous surface of the vertebras above, corning in contact with 
that of the vertebrae below, they become united with each 
other, at first by soft substance, afterwards by bony an- 
chylosis." 

Where the bones are affected by scrofula, bony an- 
chylosis does not so readily take place as where they 
retain their natural texture and hardness. Occasionally, 
portions of the ulcerated or carious bone lose their vitality, 
and having become detached, are found lying loose in the 
cavity of the abscess. The pressure of a large abscess on 
the surfaces of the contiguous vertebras may cause an exten- 
sive caries far beyond the limits of the original disease. 



18 



274 PATHOLOGICAL CONDITIONS. 

CHAPTER III. 
OF TUMOES. 

Jn giving a brief description of tumors, the following 
classification has been adopted from Gross, as presenting the 
most practical and convenient arrangement of the subject : 

I. Benign or Non-Malignant Tumors. 

1: Cystic Tumors. 

a. Simple Cysts; including Serous, Mucous, Syno- 

vial, Colloid, Sanguineous, Salivary, Milk, Oil, 
Seminal, and Dermoid Cysts. 

b. Compound or Proliferous Cysts. 

2. Hydatid Tumors. 9. Polypoid Tumors. 

3. Myxomatous " 10. Myomatous 

4. Lipomatous " 11. Vascular 

5. Fibrous " 12. Neuromatous " 

6. Cartilaginous " 13. Adenoid 

7. Osseous 14. Lymphatic 

8. Papillary 

II. Malignant Tumors. 

1. Sarcomatous Tumors. 

a. The Pound Celled. b. The Spindle Celled. 

c. The Giant Celled. 

2. Carcinomatous Tumors. 

a. Scirrhus Tumors. d. Colloid Tumors. 

b. Encephaloid " e. Epithelial " 

c. Melanotic " 

I. Benign or Non-Malignant Tumors. 

1. Cystic Tumors. These are of very frequent occur- 
rence, and may acquire an extraordinary size. Their struc- 



OF TUMORS. 27 

ture may be simple or very complex, and we may accord- 
ingly divide them into simple or barren, and compound or 
proliferous cysts. They may be new formations or, as in 
most cases, merely hypertrophies. They occur in nearly 
every organ and tissue of the body, but are most frequently 
met with in the skin and mucous membranes, the glandular 
organs, and in the subcutaneous cellular tissue. 

A. Simple Cysts generally consist of a thin sac or cyst 
filled with contents, varying according to the structure and 
function of the affected part. The cyst itself may be solitary, 
or multiple, generally composed of a single layer, its ex- 
ternal surface being rough and adherent to the surrounding 
tissues, while the internal surface is shining or glossy, and in- 
immediate but loose contact with the contents of the tumor. 

According to the nature of their contents, we may find 
the following varieties of simple cysts: 

Serous Cysts. Their contents are generally of a thin, 
watery character, slightly saline in taste, and consisting 
largely of albuminous material. The walls are thin, and at 
first translucent ; as they grow older they become thicker 
and denser. 

Mucous Cysts generally contain a thick, ropy, glutinous 
material, intermixed with epithelial matter. Sometimes the 
contents are thin and clear ; occasionally they resemble the 
fluid contained in a synovial bursa. Such tumors occur 
chiefly in connection with the mucous membranes, are gener- 
ally spherical or pyriform in shape, and may attain the size 
of a foetal head. 

Synovial Cysts are generally small in size, rounded, glob- 
ular, or hemi-spherical in shape, with contents of a serous, 
mucus, glutinous, colloid, or of a jelly-like consistence, and 
of a whitish, opaque appearance. They occur generally in 
the synovial sheaths of the tendons of the wrist, and on the 
front of the patella. The most characteristic types of syno- 
vial cysts are those known as ganglions and bursse. 



276 PATHOLOGICAL CONDITIONS. 

Colloid Cysts are rarely met with as independent struc- 
tures ; the) 7- usually occur as accidental constituents of 
various kinds of morbid growths. Their contents vary in 
consistence between mucus and the thickest jelly, " their 
color being generally whitish or pearl-like, not unfrequently 
blended with shades of pink, yellowish-brown, or olive- 
green." 

Sanguineous Cysts] or hsematomata, may be entirely new 
formations, or may occur in a normal cavity. Their con- 
tents may consist either of pure blood or of blood mingled 
with serum and other substances. " The cyst wall is usually 
very thin and smooth ; but in some cases the inner surface 
has a peculiar fasciculated appearance, not unlike that of the 
right auricle of the heart." The cyst is commonly small, 
and of a rounded or hemi-spherical shape. 

Salivary Cysts are most frequent in connection with the 
sublingual gland, constituting the so-called ranula. The 
contents of these cysts are thick and ropy, like the white of 
egg, and consist essentially of saliva, mixed with mucus and 
epithelial matter. 

Milk Cysts are liable to be formed in the mammary 
gland during lactation. Their size varies. Their contents 
may be pure milk and perfectly liquid, or mixed with caseous 
and epithelial substances. 

Oil Cysts are of rare occurrence, and usually of quite 
small size. They occur most frequently in the skin or in 
some glandular organ, especially the breast. Their contents 
are generally fatty matter, with epithelial and other sub- 
stances. 

Seminal Cysts are never of independent growth. They 
contain a fluid, mostly serum, with the characteristic sper- 
matozoa held in suspension, and only to be detected by 
the microscope. The only true tumors of this kind are 
hydroceles of the spermatic cord. 

Dermoid Cysts are usually congenital., and, in the ma- 



OF TUMORS. 277 

jority of cases, contain the debris of a blighted ovum, such 
as hairs, teeth and bone. Sebaceous tumors are a variety 
of dermoid cysts, and contain sebaceous matter, combined 
with epithelium and even hair, oil or fat. 

B. Compound or Proliferous Cysts are " characterized by 
the existence of subordinate cysts, occupied by different organ- 
ized substances, and giving rise to that peculiar arrangement 
known as multilocular or polycystic, generally so conspic- 
uous in this class of tumors." When a number of cysts are 
crowded together, their walls are frequently absorbed, and 
irregular cavities, varying in size and shape, are thus formed. 
Their contents are of the most diversified character. The 
cyst wall is thin at first, but becomes thicker and firmer in 
a later stage. 

Proliferous cysts sometimes take on a malignant character, 
of the encephaloid or epithelial type, years after their origin. 
They occur most frequently in the ovary, the mammae, and 
the thyroid gland. In the first situation, they not unfre- 
quently attain an enormous size. 

2. Hydatid Tumors. These tumors occur most fre- 
quently in the liver, ovary and uterus. They consist of a 
distinct sac, enclosing an entozoon, parasite or vesicular 
worm, "varying in volume between a mustard-seed and a 
small orange. The entozoon is of a globular figure, of a 
whitish, semi-opaque appearance, and composed of a vesicle 
or bladder, filled with serous fluid, and surrounded by a cel- 
lulo-fibrous capsule." Generally a number of them are found 
in a common cyst. " The contents of the animal are of a 
clear, limpid character, remarkably saline to the taste, but 
destitute of odor and coagulability. Between the cyst and 
the parasite there is commonly a soft, pulpy, dirty-looking 
substance, the precise nature of which is undetermined. 
Large hydatids sometimes contain several smaller ones, one 
within the other." 



278 PATHOLOGICAL CONDITIONS. 

" The inner surface of the parasite is studded with numer- 
ous little bodies, resembling diminutive fish-spawn, hardly 
as large as a grain of sand, of a spherical shape and of a 
grayish color, each consisting of a delicate cyst, filled with 
echinococci." 

"Each echinococcus consists of a body and a head, the 
latter being encircled by a row of teeth, naturally concealed 
in a narrow cleft, but capable of projecting itself. The body, 
composed of solid, granular matter, has a curiously speckled 
appearance, due to the presence of numerous ovoid spots 
immediately beneath its outer coat. The teeth, or hooklets, 
are spinous, sharp, and perfectly characteristic." 

3. Myxomatous Tumors. The Myxomata or mucous 
tumor, consists of mucous tissue, a translucent and succulent 
connective tissue, the intercellular substance of which yields 
mucin. Their characteristic features are elasticity and soft- 
ness ; the older growths, however, are harder than the more 
recent ones. They are of a pale, greyish or reddish-white 
color. They consist of a basement structure, the proper 
stroma of the tumor, and an intercellular substance, pervaded 
by distinctly visible blood-vessels. On being cut, they yield, 
on pressure, the tenacious, mucilaginous, intercellular liquid, 
in which may be seen the cellular elements of the growth. 
The majority of the cells, under the microscope, are found to 
be angular and stellate, with long, anastomosing prolonga- 
tions and trabecule. Others are isolated and fusiform, oval 
or spherical in shape. They usually possess one, in some 
cases two distinct nuclei. Fat cells, fibrous tissue, both 
white and elastic, and cartilage in varying proportions, are 
often met with in the morbid mass. 

They occur chiefly in the subcutaneous and intermuscular 
cellular tissues, in the mucous cavities, in the hilus of the 
kidney, and in the nerves and bones. When situated in 
superficial parts they may become pedunculated. In the 



OF TUMORS. 279 

submucous tissue of the nose they constitute the gelatinoid 
polypus. Other perfect types of mucous tumors are seen in 
the polypi of the ear and the uterus. 

4. Lipomatous Tumors. The Lipomata or fetty tumors 

are very common, and may occur in any part of the body. 
There may be but one, or they may appear in very large 
numbers in different parts of the body. They sometimes 
attain an enormous size. They are lobulated, and are 
usually surrounded by a fibrous capsule, which separates 
them from the adjacent structures. Their consistence varies 
according to the amount of fibrous tissue that enters into 
their formation. They frequently become pedunculated, or 
assume a pyriform shape, no doubt by reason of their 
weight, by which they are gradually dragged out of their 
original shape, as well as position. They resemble in 
structure, as also in appearance on section, adipose tissue. 
They consist of more or less round or polygonal cells, disten- 
ded with fluid fat, and united into masses or lobules of various 
sizes by connective tissue, which also forms a sort of capsule 
around the tumor, and connects it more or less firmly to the 
parts around. 

Inflammation, suppuration, ulceration, and even gangrene 
may occur in these growths. They may also undergo at 
certain points, fibrous, cartilaginous or osseous degeneration. 
Cysts filled with various kinds of substances may also 
occasionally occur within them. 

5. Fibrous Tumors. The Fibromata appear in very 
different parts of the body, commonly in those which nor- 
mally contain much fibrous tissue. Several may exist in 
the same organ, more particularly in the uterus, rarely do 
they co-exist in" separate organs. Their form is mostly 
spherical, generally with a smooth, even surface, although 
not unfrequently it is lobulated, or marked by numerous 



280 PATHOLOGICAL CONDITIONS. 

elevations and depressions. They feel heavy and incom- 
pressible. Near a free surface they are prone to become 
pedunculated. They may attain a very great size. Their 
vascularity is in proportion to the density of their structure, 
some having but few vessels, while others are highly vas- 
cular. A distinct capsule is but seldom met with, although 
the tissues around the tumors will usually be found a great 
deal condensed and thickened. 

They consist essentially of fibres, resembling those of 
areolar tissue. "Sometimes the fibres are tolerably distinct 
and separate, more often so interlaced and blended together, 
or so imperfectly evolved that they cannot be made out as 
such. Yellow elastic fibres are not unfrequently mingled 
with the white." 

Growths of this kind are not, in general, liable to any 
great degree of change. Inflammation, with injection and 
softening of the part may take place. Cretifi cation may 
occur, by which either the whole tumor may be converted 
into a calcareous mass, or only the outer stratum surrounding 
the rest as a kind of shell. 

6. Cartilaginous Tumors. The Unchondromata, his- 
tologically resemble cartilage, and like it consist of cells and 
an intercellular substance, presenting all the variations 
observed in the normal tissue. The intercellular substance 
may be hyaline, fibrous, or mucoid, or as most frequently is 
the case, all combined. The cells are round, oval, spindle- 
shaped or stellate, and may be very numerous, or few in 
proportion to the matrix. They enclose one or more nuclei, 
and slightly granular contents ; sometimes a cell- wall cannot 
be distinguished. 

In addition to the intercellular tissue, the growth is 
usually divided into several lobes by bands of fibrous tissue. 
The fibrous tissue in most cases, forms a capsule around the 
tumor, and separates it from the surrounding structures. 



OF TUMOR?. 281 

The enchondroma is met with most frequently in early life, 
and occurs chiefly in connection with the osseous system, 
principally the metacarpal bones, and phalanges of the 
fingers, where it may grow either from the periosteum or 
from the medulla. It is met with also in the parotid and 
submaxillary glands, in the testicle, mammae and ovary, and 
occasionally in the subcutaneous and intermuscular cellular 
tissue. 

They may attain an enormous size. "To the hand, it 
imparts the sensation of unusual firmness and solidity ; it is 
destitute of elasticity, is generally distinctly circumscribed, 
and is nearly always strongly adherent to the tissues from 
which it springs." 

Calcification and ossification of these tumors may occur. 
In rare cases, the skin covering the tumor ulcerates, and a 
fun gating mass protrudes. 

Although in general an innocent growth, the enchondroma 
in some instances, assumes a malignant form, and recurs 
after extirpation. 

7. Osseous Tumors. The Osteomata are tumors con- 
sisting of osseous tissue, met with chiefly as outgrowths of 
the skeleton, especially of the external and internal surfaces 
of the skull, and of the thigh bone. 

There are three classes, the soft, spongy or cancellous, 
the compact, and the eburnated osteoma. 

The spongy, which is the most common, consists of can- 
cellous osseous tissue. The medullary spaces may contain 
embryonic tissue, a fi brillated tissue, or fat. " In its earlier 
stages, it is often invested by a layer of cartilage, of a green- 
ish, whitish, slightly bluish, or pearly aspect, and of a 
hyaline character. Sometimes it is enclosed by a thin, 
fibrous, or fibro-cellular capsule, a form of synovial bursa, 
lubricated by serous or sero-oleaginous fluid." 

The compact osteoma is generally more or less rounded, 



282 PATHOLOGICAL CONDITIONS. 

with a nodulated surface, and a broad base. It is of a firm, 
bony consistence, and resembles, as nearly as possible in 
.structure, the compact tissue of the long bones, differing only 
in the arrangement of the Haversian canals and canaliculi, 
which is less regular than in normal bone. 
. The ebumated osteoma consists of dense osseous tissue. 
The lamellae are arranged concentrically and parallel to 
the surface of the tumor. Blood-vessels and cancellous 
tissue are both absent. The tumor is of small size, rounded, 
globular or hemi-spherical in shape, and generally smooth, 
or slightly nodulated. 

8. Papillary Tumors. The Papillomata resemble in 
structure ordinary papillae, and like these grow from cuta- 
neous and mucous surfaces. 

They consist of a basis of connective tissue, supporting 
blood-vessels, which terminate in a capillary net-work, or 
in a single capillary loop, the whole being enveloped in a 
covering of epithelium, varying in character according to the 
surface from which the new formation springs. These 
growths are sometimes very vascular. 

On the skin we may have these growths as warts and horny 
growths. These are commonly firm, with a dense epithelial 
covering, and are less liable to ulceration and haemorrhage, 
than those growing on other parts. But we have, in the 
condylomata and venereal ivarts, occurring around the anus 
and upon the external male and female genital organs, in- 
stances of larger and more vascular forms on cutaneous 
surfaces. 

On the mucous membranes, the papillomata are softer 
and more vascular, and have a less dense epithelial cover- 
ing. Many of them constitute so-called mucous polypi. 
They are met with on the tongue, in the larynx and nose, 
in the gastro-intestinal mucous membrane, on. the cervix 
uteri, and in the bladder. 



OF TUMORS. 28 



9. Polypoid Tumors. Those growths occur exclusively 
in the mucous cavities of the body, and may attain a large 
size. 

They occur most frequently in the nose and the uterus, 
but are also met with in the ear, maxillary sinus, vagina 
and rectum, while their presence in the larynx and throat 
is exceedingly rare. 

They are usually solitary, varying in size and shape 
according to the locality which they occupy. 

Four varieties are met with, differing essentially in their 
structure. 

The gelatinoid polypus, the most common of all, occurs 
almost exclusively in the nose. It is of a jelly-like appear- 
ance, irregularly pyriform in shape, with a narrow pedicle, 
sometimes nearly an inch in length. It is nourished by a few 
straggling vessels, which are often of considerable length 
and thickness. 

The structure of the fibrous polypus is exceedingly dense 
and composed of fibres, interlacing with each other in all 
directions. It is tough, hard and incompressible ; of a red- 
dish, purple or livid hue. It is nearly always solitary, may 
attain a large size, and is usually attached firmly by a broad 
base, and not by a pedicle. The uterus, nose and maxillary 
sinus, are its most common sites. 

The granular polypus, is of rare occurrence. It is met 
with chiefly in the uterus and in the ear. It is generally 
small, of a pale, greyish, or whitish color, soft and fragile 
in consistence, and globular, conical, or ovoidal in shape. 
Its structure is granular, homogeneous and inelastic. 

The vascular polypus, attached usually by a narrow base, 
is of a florid color, of a soft consistence, and not very large 
in size. On section we find numerous vessels interspersed 
throughout a fibro-cellular tissue. 

Carcinomatous disease is more liable to supervene in the 
case of the fibrous growths, than in the other of these 
formations. 



284 PATHOLOGICAL CONDITIONS. 

10. Myomatous Tumors. The Myomata are tumors 
consisting of muscular tissue, either of the striated, or non- 
striated variety. The former are exceedingly rare and gen- 
erally congenital, the latter are quite frequent and are never 
congenital ; but occur principally in elderly subjects. 

They are met with most frequently in the uterus, where 
they sometimes attain an immense size. They form either 
distinctly circumscribed tumors of a globular, conical, or 
pyriform shape, or ill-defined masses in the uterine walls. 
When projecting into the cavity of the uterus, or into the 
abdominal cavity, they assume the shape of polypi, with a 
narrow pedicle. 

Myomata may also occur in the prostate gland, in the 
oesophagus, stomach and intestines. 

"In structure they consist of elongated spindle-shaped cells, 
more or less isolated, or grouped into fasciculi of various 
sizes, with a varying amount of connective tissue." 

Maceration with dilute nitric acid, is often necessary in 
order to isolate and display the muscular elements. 

11. Vascular Tumors. The Angiomata are tumors 
consisting of blood-vessels, held together by a small amount 
of connective tissue. They include the various forms of 
nsevi, the erectile tumors, and aneurism by anastomosis. 

They are generally met with as congenital affections. 
Their ordinary sites are the skin and mucous membranes, 
especially about the head, face and tongue. 

They are soft and spongy, easily compressible, and very 
elastic, varying in color according to the nature of their con- 
tents, whether venous or arterial, or both combined. 

12. Neuromatous Tumors. True Neuromata are 
tumors consisting almost entirely of nerve tissue. The 
term has also been applied to growths of other kinds, found 
in connection with nerves ; these are false or spurious neuro- 



OF TUMORS. 285 

mata. True neuromata are of very rare occurrence. They 
consist mainly of a new growth of nerve fibres. " They 
resemble in structure the cerebro-spinal nerves, consisting of 
tubular fibres, with a varying quantity of intertubular 
connective tissue, and in some cases a few gray, gelatinous 
fibres." They usually exist as small, single nodules, solid 
to the touch, firm, inelastic, and developed within the neuri- 
lemma of the affected nerve. 

The most frequent seat of these growths is the extremi- 
ties of divided nerves, where they sometimes occur after 
amputation. They may also exist in the course of the 
nerves, in any situation, singly, or in great numbers. 

13. Adenoid Tumors. The Adenomata are new for- 
mations of gland tissue, resembling in structure the racemose, 
or tubular glands. "They consist of numerous small saccules 
or tubes filled with squamous or cylindrical epithelial cells. 
These are grouped together, being merely separated by a 
small, though varying amount of connective tissue, in which 
are contained the blood-vessels." They are essentially local 
hyperplasias. The new growth may remain in intimate 
relation with the adjacent gland, or it may gradually become 
separated from it by the formation of a fibrous capsule. 

The adenoma is usually a solitary tumor, of a firm, dense-, 
inelastic consistence, of a whitish, grayish, or pale straw 
color, seldom larger than a hickory-nut. On section, the cut 
surface has a glistening appearance, and in recent cases 
never yields any fluid on pressure. 

It occurs in the mammary, thyroid, prostate, and parotid 
glands, and in the mucous follicles. In mucous surfaces, it 
gradually projects above the surface of the membrane, so as 
to form a polypus, and thus constitute the most common 
form of mucous polypus. 

14. Lymphatic Tumors. "The Lymphomata are new 



286 PATHOLOGICAL CONDITIONS. 

formations consisting of lymphatic, or as it is more com- 
monly called, adenoid tissue. This tissue consists essen- 
tially of a delicate reticulum, within the meshes of which 
are contained the so-called lymph corpuscles. The reti- 
culum is made up of very fine fibrils, which form a close 
net-work, the meshes of which are only sufficiently large 
to enclose a few, or even a single corpuscle in each. The 
fibrils usuallypresentamore or less homogeneous appearance, 
and amongst them there are a few scattered nuclei." 

The lymphatic tumor is most frequently met with in the 
lymphatic glands of the neck, axilla, groin, and mesentery, 
and usually consists of several enlarged glands, fused into 
one common mass of variable size, shape, and consistence. 
The sectional surface is of a grayish, light pink, or reddish- 
yellow color, and yields on pressure a whitish, lactescent 
juice, not unlike that of certain forms of carcinoma, contain- 
ing cells with one or more nuclei. 

II. Malignant Tumors. 

1. Sarcomatous Tumors. The Sarcomata are tumors 
consisting of embryonic connective tissue. This differs from 
the fully developed tissue, in consisting almost entirely of 
cells, which are also larger and rounder than those of 
mature tissue. Its intercellular substance, instead of being 
fibrous, is soft and amorphous or only obscurely fibrillated. 

The cells of sarcoma are round, spindle-shaped or stellate, 
and exist either separately or in conjunction in the same 
tumor. The latter is most frequently the case ; but one 
form generally predominates, and according to the prepon- 
derance of one or the other kind of cell, these tumors can be 
most conveniently classified as round-celled, spindle-celled, 
and giant-celled sarcomata. 

Round cells are found in all sarcomata, and are often very 
small, scarcely distinguishable from lymphatic cells, or white 



OF TUMORS. 287 

blood corpuscles. Others are larger, and contain an indis- 
tinct nucleus, with one or more bright nuclei. 

The fusiform or spindle-shaped cells are the so-called 
fibro-plastic cells. They are long, dimly granular, pale 
bodies, terminating at each end in a fine prolongation. 
They are slightly granular, and enclose a long, oval nucleus, 
with or without nucleoli. In size they vary. 

The giant or mother cells are the largest of human cells, 
irregular in shape, though usually more or less spherical. 
They are finely granular, and contain numerous round or 
oval nuclei, each with one or more bright nucleoli. 

The intercellular substance exists usually in small quan- 
tities. "It may be perfectly fluid and homogeneous, or 
firmer and granular, or, less frequently, more or less fibril- 
lated. Chemically, it yields albumen, gelatin and mucin." 

These growths may occur at any period of life, but are 
most frequently met with between the twentieth and fortieth 
year. It is most common in the skin and subcutaneous and 
intermuscular connective tissues of the extremities. The 
periosteum and bones, particularly the epiphyses of the long- 
bones and the maxilla?, the female breast, the testicles, and 
the eye, are also liable to be attacked. 

They usually arise as nodules, single or multiple, firm or 
soft, and often attain an enormous size by their characteristic 
rapidity of growth. They are liable to fatty degeneration, 
with the production of cyst-like cavities. Calcification, 
ossification and mucoid degeneration are also common. 

Sarcomata are decidedly malignant, and are characterized 
by their rapid growth, their great tendency to extend locally, 
and to recur after removal, and by their power of repro- 
ducing themselves in internal organs. 

The Bound-celled /Sarcoma, called also from its resem- 
blance in many cases to encephaloid, medullary, encepkaloid 
or soft sarcoma, is of a uniform, soft, brain-like consistence, 
and of a somewhat translucent, greyish, or reddish-white 



288 PATHOLOGICAL CONDITIONS. 

color. The sectional surface, on being scraped, yields a juice 
rich in cells. It is exceedingly vascular, with the vessels 
often dilated and varicose. " It can be distinguished from 
encephaloid cancer by the absence of a fibrous stroma, by 
the uniformity in the character of its cells, and by the 
absence of any invasion of the surrounding structure in their 
growth other than the connective tissue from which they 
grow." 

The Spindle- celled Sarcoma, called also the fibro-plastic 
and recurring fibroid, is most closely allied to the fibroma. 
It consists essentially of fusiform cells, with well-marked 
nuclei and thin processes, sometimes split at the end. They 
are nearly in close contact, there being but little intercellular 
substance. The cells are parallel and arranged in bundles, 
which pass in all directions through the growth. " When 
cut, this sarcoma grates under the knife, and the surface 
exhibits a firm, tough, greyish or pale^ellowish appearance, 
similar to that of ordinary fibrous growth. After removal, 
they are softer and more succulent when they recur." 

They grow from the periosteum, the fasciae, and from the 
connective tissue in other parts. They are more frequently 
enclosed in a capsule than the other varieties. 

The Giant- celled Sarcoma, called also the myeloid sarcoma, 
most frequently occurs in connection with bone. They consist 
of large, many nucleated cells, mingled with round or spindle 
forms, nearly in contact, there being but a sparse inter- 
cellular substance. On section, the surface appears smooth, 
compact, shining, greyish- white or greenish, with blotches 
of a dark crimson, brownish or pink hue. 

The giant-celled sarcoma is not a benign affection, but is 
the least malignant of the sarcomas. 

2. Carcinomatous Tumors. " The Carcinomata are 
new formations, consisting of cells of an epithelial type, 
without any intercellular substance, grouped together ir- 



OF TUMORS. 289 

regularly within the alveoli of a fibrous stroma. The cells 
are characterized by their large size, by the diversity of 
their forms, and by the magnitude and prominence of 
their nuclei and nucleoli. In size they vary from 6 Jq to 
jsoo of an inch in diameter, the majority being about five 
times as large as a red blood-corpuscle. They are round, 
oval, fusiform, caudate, polygonal — exhibiting, in short, 
every diversity of outline. The nuclei, which are large and 
prominent, are round or oval in shape, and contain one or 
more bright nucleoli." There is generally but a single 
nucleus, two, however, are often met with, and they are 
even still more numerous in the soft varieties of cancer. 

The stroma varies in amount. It consists of a fibrillated 
tissue, forming by their peculiar arrangement, alveoli of 
various sizes and shapes, in which the cells are grouped. 
The stroma varies in character according to the rapidity of 
its growth. Where its growth is rapid, it will contain 
numerous round and spindle-shaped cells ; where it is slow, 
or has ceased altogether, the tissue will contain but few cells, 
and will be dense and fibrous in character. The latter con- 
dition is most frequently met with. 

The blood-vessels are sometimes very numerous, and are 
always limited to the stroma, and never encroach upon the 
alveoli. This serves to distinguish the carcinomata from 
the sarcomata, since in the latter the blood-vessels ramify 
amongst the cells of the growth. 

The carcinomata also possess lymphatics, and it is owing 
to this that the lymphatic glands are so constantly involved 
in the disease. 

Cancers very rarely become encapsuled, but generally 
invade the surrounding structures. The epithelial elements 
are found infiltrating the tissues for some distance around 
the tumor, so that there is no line of demarcation between 
it and the normal structures. 

19 



290 PATHOLOGICAL CONDITIONS. 

Carcinomatous tumors are liable to certain alterations and 
transformations, like other morbid growths. 

Fatty degeneration is the most common of these. This 
occurs to a greater or less extent in all the varieties of 
cancer. It produces softening of the growth, which is often 
reduced to a pulpy, cream-like consistence. 

Calcareous degeneration has been occasionally met with 
in encephaloid, and in carcinoma invading bone. 

Inflammation, softening, and consequent ulceration, are 
not unfrequent. 

The varieties of carcinomata are : 

(a.) Scirrhus. Scirrhus, fibrous, hard or chronic cancer, 
seldom occurs before middle age, and more frequently in the 
female than male. 

The liver, mammae and uterus, are particularly liable to 
be attacked. It also occurs in the alimentary canal, and in 
the skin. 

Scirrhus is characterized by the large amount of its 
stroma, and its slow growth. The tumor is firm, hard and 
inelastic, of variable shape, and is often depressed in the 
centre, owing to the contraction of the cicatricial tissue. 

On section, especially in the more matured stages, the 
tumor exhibits a whitish, glistening aspect, intersected with 
fibrous bands, the remains of normal tissue, changed by 
disease. It yields on being scraped, a peculiar fluid, the 
so-called cancer juice, generally of a pale, grayish, turbid 
appearance, rich in cells, nuclei and granules, sometimes of 
a whitish, creamy hue. This juice is evidently the result of 
disintegration, and is hence but sparingly present in recent 
specimens. It readily mixes with water, and often contains 
a quantity of free oil. 

Scirrhus has but few blood-vessels. Nerves and lym- 
phatics also exist. It has a tendency to ulcerate, and to 
contract adhesions with the structures surrounding it. The 
lymphatic glands are also liable to be infected, by the con- 



OF TUMORS. 291 

roving of cancer elements to them through the lymphatic 
vessels situated in the scirrhus mass. 

(b.) Encephaloid. Encephaloid, medullary, soft or acute 
cancer, differs from the preceding, in the small amount of 
stroma, the consequent softness of consistence, and its rapid 
growth. 

It is most common in the mammse, eye, testicle, uterus, 
liver, lymphatic glands, periosteum and bones. The greatest 
number of cases occur between the twentieth and fiftieth 
years. 

The cells are exactly similar to those of scirrhus, but 
far more numerous, while the stroma is not so well marked, 
and much less fibrous, and does not undergo a similar cica- 
tricial contraction. 

Blood-vessels are very abundant. 

The tumor varies in size from a pea to that of an adult's 
head, its shape being generally ovoidal, and its surface more 
or less tabulated. "It is of a soft, brain-like consistence, 
the central portions, where fatty degeneration is most 
advanced, often being completely diffluent. On section, it 
presents a white, pulpy mass, much resembling brain sub- 
stance, which is often irregularly stained with extravasated 
blood." 

Occasionally these tumors contain serous cysts of small 
size, as well as other adventitious products. When ulcer- 
ation takes place, the sore is characteristic. " Its edges 
are thin, undermined, jagged, or irregular, while its bottom 
has a foul, bloody, fungous appearance. The parts around 
are of a deep red, livid, or purple color." 

(c.) Melanosis. Melanotic, or black cancer, is probably 
merely the result of a pigmentation of the encephaloid. It 
occurs most frequently in the eye and skin, and is occa- 
sionally met with in the viscera. The melanotic matter 
occurs in small masses, of a rounded, ovoidal, or irregular 
shape, with or without a cyst, from the size of a pin's head 



292 PATHOLOGICAL CONDITIONS. 

to that of a walnut; of a dull, sooty, brownish, or black 
color. They are generally invested by a distinct capsule, 
formed out of the cellular tissue in their immediate vicinity. 

"Under the microscope, it is seen to consist of a fibrous 
net-work, including numerous alveoli, filled with free, unad- 
herent pigment cells, occupied by colored granules, a few of 
the larger or older ones containing sometimes a nucleus with 
its nucleolus. Free pigment granules are also found in 
:great abundance." 

(d.) Colloid. The colloid, alveolar, gelatiniform cancer, 
is the most uncommon form of heterologous formations. It 
lis -regarded by some, as simply one of the preceding forms 
which has undergone mucoid or colloid change. 

It is most frequently met with in the stomach, the in- 
testines, and the periosteum ; and can appear at any age, but 
is most common between the thirty-fifth and fiftieth year. 

The tumor varies in size, from the size of a marble to an 
adult head, is globular or irregular in shape, of a firm, dense 
consistence, with a rough, knobby, or distinctly lobulated 
surface. 

The stroma, of a fibrous character, of a dull, whitish, 
grayish, or pale-yellowish color, and great density, is so ar- 
ranged as to form numerous alveoli of various sizes and 
shapes, communicating with each other. Within these 
cavities is contained the gelatinous or colloid material, 
which is a glistening, whitish, greenish, or yellowish color, 
and of the consistence of thin mucilage or ordinary jelly. 
In the older cells it becomes more firm and opaque. "In 
the main, it is perfectly, structureless ; within it, however, 
are imbedded a varying number of spherical cells, which 
also contain the same gelatinous substance. These cells 
present a peculiar appearance ; they are large and spherical 
in shape, and are distended with drops of the same gelatinous 
material as that in which they are imbedded. Many of 



OF TUMORS. 293 

them display a lamellar surface, their boundary consisting 
of concentric lines." 

(e.) Epithelioma. Epithelioma, cancroid, or epithelial 
cancer, grows in connection with cutaneous and mucous 
surfaces. 

The cells, usually containing a single nucleus, resemble 
very closely those met with in the cutaneous surfaces, and 
in the mucous membrane of the mouth, only that they are 
larger, their average being about 7 J of an inch. In shape 
they are either rounded, oval, angular, or elongated, accord- 
ing to the pressure to which, in their growth, they are 
subjected. They are closely packed together into nests, 
assuming a concentric arrangement, like the layers of an 
onion. 

Mixed up with the cells, especially if the growth have 
made much progress, are great numbers of free nuclei and 
granules, and sometimes also crystals of cholesterine, pig- 
ment cells and blood corpuscles. 

"The tumor itself is firm in consistence, more or less friable, 
and on section presents a grayish-white granular surface, 
intersected with lines of fibrous tissue. The cut surface 
yields on pressure, a small quantity of turbid fluid, and in 
most cases also a peculiar thick, crumbling, curdy material, 
can be expressed, which comes out in a worm-like shape, 
like the sebaceous matter from the glands of the skin." 
The ulcer formed has a foul, fungating appearance, with 
irregular granulated edges, and a hard rough base. 

The disease is more common in men than women, and 
seldom occurs before the age of thirty-five or forty. It is 
most frequently met with in the lower lip, in the tongue, 
prepuce, scrotum, (" chimney-sweep's cancer,") labia, eye- 
lids, cheeks, in the uterus and bladder. As it extends it 
may involve any tissue. 



294 PATHOLOGICAL CONDITIONS. 



CHAPTER IV. 

POSTMORTEM APPEARANCES IN DEATH 
FROM UNNATURAL CAUSES. 

1. Death from Poisoning. 

In speaking of the lesions produced by poisoning, we will 
confine our attention to the more common poisonous sub- 
stances which are given, or taken, either intentionally or by 
accident, and which may result in death. 

Sulphuric Acid. Death from poisoning with this acid, 
commonly results in from twelve hours to three days, but 
sometimes life is prolonged for a week or a fortnight, or for 
months, and sometimes death may take place in an hour. 

The morbid appearances met with will vary according to 
the quantity of the acid taken, and the manner of its admin- 
istration. The appearances are in general as follows : 

On the lips, fingers, or other parts of the skin, spots and 
streaks of a brownish, or yellowish-brown color are met 
with, where the acid has disorganized the cuticle. 

The mucous membrane of the tongue and fauces is white ; 
the pharynx is only in the rarest cases carbonized like the 
stomach, is generally hard to cut, as if tanned, and of a gray 
color ; the vascular injections of its mucous membrane may* 
be recognized. 

The rima glottidis is sometimes contracted, the epiglottis 
swelled, and the commencement of the larynx inflamed. 
The oesophageal membrane is often completely detached, or 
comes off in shreds, and the passage shows traces of the 
corroding effects of the poison. 

The outer surface of the abdominal viscera is commonly 
either very vascular or livid. 



EFFECTS OF POISONS. 295 

The stomach, if not perforated, is commonly distended 
with gases, and contains a quantity of yellowish-brown or 
black matter, and is sometimes lined with a thick paste, 
composed of disorganized tissue, blood and mucus. The 
pylorus is contracted. If the acid has been taken diluted, 
the mucous membrane is merely excessively injected, with 
blackness of the vessels, and usually a softening of the rugae, 
or actual removal of the villous coat. 

• If the stomach be perforated, the holes are commonly 
roundish, with thin, colored and disintegrated margins, and 
surrounded by vascularity and black extravasations. The 
inner coat of the duodenum often presents appearances 
closely resembling those noticed in the stomach. Some- 
times, especially in cases which are rapidly fatal, it is not at 
all affected, probably owing to the spasmodic contraction of 
the pyloric orifice. 

The urinary bladder is commonly empty. 

The blood is thickened, and of an acid reaction. 

Nitric Acid. The appearances observed in cases of 
poisoning by this acid, are similar to those noticed under 
sulphuric acid. A difference of tint in the color produced 
by nitric acid on the skin, lips and mucous lining of the 
mouth and oesophagus, being the only distinguishing mark. 
Whereas in the case of sulphuric acid the color is brownish, 
in the case of nitric acid, it is most frequently yellow. 

Oxalic Acid. This is a poison of great energy, and so 
more frequently used for committing suicide than for pur- 
poses of murder. It has often been taken by accident for 
Epsom salt, (sulphate of magnesia,) which it greatly resem- 
bles in general appearance. 

It is the most rapid and unerring of all the common 
poisons, and produces death generally within an hour, 
although a large dose may prove fatal in two or three 



296 PATHOLOGICAL CONDITIONS. 

minutes, and a smaller one may be survived for as long 
as twenty-three days. 

The mucous membrane of the throat and oesophagus look 
as if scalded, and can easily be scraped off. The stomach 
contains a thick fluid, commonly dark, like coffee-grounds. 
The inner coat of the stomach is pulpy, in some points 
black, in others red. 

The mucous membrane of the intestines is usually simi- 
larly, but less violently affected. In some cases, the stomach 
and intestines have been found healthy. 

Phosphorus. This substance has frequently, in the 
form of heads of lucifer matches, been the cause of death ; 
more frequently taken by accident, or with the intention of 
committing suicide, than with the design of destroying the 
lives of others. 

The symptoms of phosphorus poisoning vary during life, 
and after death the morbid appearances are not constant, 
depending much upon the length of time that has elapsed 
before death. 

In cases which have proved rapidly fatal, the main 
appearances are those of irritation, somewhat similar to 
those already described, and due to the direct action of the 
poison. In more protracted cases there is generally jaundice, 
the blood is found in a state of complete fluidity, non-coagu- 
lable, and with very few corpuscles, while ecchymoses and 
sanguineous effusions appear everywhere. 

Sometimes the stomach is distended with gas, which 
stinks of garlic. The mucous membrane is partly ash- 
colored, partly of a dark, purplish-reel, and exhibits gan- 
grenous ulcers which penetrate deeply into the muscular 
coat. In recent cases, the whole contents of the stomach 
shine in the dark, especially when gently warmed. 

The liver is greatly altered, an acute fatty degeneration 
is found to have taken place in its secreting structure. The 



EFFECTS OF POISONS. 297 

acini arc sometimes found filled with fat. even to bursting; 
but more commonly they are wholly destroyed, and oil and 
fat globules fill their place. 

The secreting structures of the kidneys are also found in 
a state of fatty degeneration, and the ducts are sometimes 
filled with exudation matter. The heart and the muscles 
generally also show signs of the same fatty degeneration. 

Arsenic. This is the poison most frequently chosen for 
the purpose of committing both suicide and murder. 

Arsenic produces two classes of phenomena, one is purely 
irritant, by virtue of which it induces inflammation in the 
alimentary caaal and elsewhere ; and the other consists in a 
disorder of parts of organs remote from the seat of its 
application. It is absorbed by the blood, which in most 
cases of acute poisoning, is found in a remarkable state 
of fluidity, and can be detected in the liver, the spleen, and 
in the urine. It acts with nearly the same energy, what- 
ever be the organ or tissue to which it is applied. 

From two to three grains have proved fatal, but an 
instance is recorded of recovery after a dose of sixty grains. 
Death may ensue in half an hour, or may be delayed for 
nearly three weeks ; the usual time is perhaps from twelve 
to forty-eight hours. There are some cases in which little 
or no morbid appearances are to be seen. 

Usually, however, traces of irritation will be discoverable. 
In the mouth and throat they are often wanting. The 
inner surface of the stomach may be red and inflamed, or 
blackish from the extravasation of blood, or softened, or 
in some cases thickened, with the rugae raised and cor- 
rugated. Ulceration of the coats of the stomach is but 
rarely met with, unless the patient have survived nearly 
two days. The mucous secretion is generally increased in 
quantity, sometimes thin, and viscid, as in its natural state, 
but sometimes solid, as if coagulated. In the latter case, it 



298 PATHOLOGICAL CONDITIONS. 

forms either a uniformly attached pedicle, or loose shreds 
floating among the contents. 

A very common appearance, is the presence of a sanguin- 
olent fluid, or even actual blood in the cavity of the stomach. 

The poison itself may also be found within the stomach. 
The intestines may be congested and inflamed throughout 
their whole length, but most frequently only in the duo- 
denum and rectum. 

Within the chest, redness of the pleura, redness and con- 
gestion of the lungs, have been noticed. 

In general, arsenic retards the process of putrefaction 
after death. 

The forms in which arsenic is most frequently used for 
the purpose of poisoning, are arsenious acid, and the 
arsenite of copper, Scheele's green. 

Corrosive Sublimate. The appearances observed in 
the bodies of persons killed by this poison, are very similar 
to those excited by the irritant poisons already noticed. 

The mouth and throat are more frequently affected than 
by arsenic. The tongue is often shrivelled, and the papillae 
at its root greatly enlarged. The mucous membrane is 
swollen and whitened. The same appearances are generally 
noticed in the oesophagus. The coats of the stomach and 
intestines, more particularly the colon and rectum, have 
been found congested and inflamed, and sometimes destroyed, 
either by a chemical decomposition of the tissues, or by 
ulceration. 

The bladder is often excessively contracted ; the kidneys 
usually much congested and inflamed. Inflammation of the 
peritoneum, and effusion into its sac are frequent results of 
poisoning with corrosive sublimate. 

Hydrocyanic Acid. The poisons whose energy depends 
upon the presence of this acid, surpass almost all others in 






EFFECTS OF TOISONS. 299 

rapidity of action, and the minuteness of the quantity in 
which they operate. 

The lesions produced are uncertain. The spine and neck 
are stiff, the abdomen retracted, the skin usually livid. 

The body, generally the blood, serous cavities, stomach 
and the various tissues usually exhale, for some time after 
death, the characteristic odor of the acid. Turgescence of 
the venous system, and emptiness of the arterial system, are 
commonly remarked throughout the body. The stomach 
and intestines are congested and red. The liver and lungs 
are gorged with blood. 

Strychnia — Nux vomica. In poisoning with this 
substance, the rigidity of the body which exists during life, 
is frequently retained for hours after death. There is con- 
gestion of the membranes of the brain and spinal cord. 

The stomach is frequently quite natural in appearance, as 
also the intestines, although occasionally signs of irritation 
are noticed in both. 

Alcohol. In death from alcohol, the body is slow to 
putrify, and the internal organs exhale no cadaveric odor, 
but rather that of recent flesh, or in some cases a faint odor 
of brandy. The appearances constantly found are, hyper- 
emia of the brain, sometimes cerebral haemorrhage ; hyper- 
emia of the large abdominal veins, or hyperemia of the 
lungs and heart, and always visible fluidity and dark color of 
the blood. 

Carbonic Oxide. This is the poisonous ingredient of 
illuminating gas, and is generated by burning charcoal. 
It is usually in one of these forms that it is the cause of 
death. 

The most characteristic appearance after death, is the 
bright cherry-red color of the heart. There is, also, hyper- 
emia of the lungs and of the right side of the heart. 



300 PATHOLOGICAL CONDITIONS. 

Opium. In cases of death from this substance, lividity 
of the skin is usually present. 

Turgescence of the vessels of the brain, and watery 
effusion into the ventricles are generally met with. 

The lungs are sometimes found gorged with blood. The 
stomach is occasionally red, but decided inflammation is 
rare. The blood is always fluid, and the body is apt to 
pass rapidly into putrefaction. 



2. Death from Suffocation. 

By suffocation is meant that condition in which the sys- 
tem is prevented from receiving the necessary amount of 
oxygen though the lungs. The term is generally restricted 
to a condition arising from the obstruction of the air passages, 
either internally, or from without, or from the breathing of 
irrespirable gases. (The latter form being attended also by 
blood-poisoning, which we have already noticed.) 

The appearances noticed are the following : 

The face may be more or less bluish-red, swollen, with 
protruding eyes, or differing in no respect from that observed 
after other kinds of death. Froth is often observed coming 
out of the mouth. 

There is a universal and unusual fluidity and dark color 
of the blood. Hypersemia of the right side of the heart, 
while the left is either entirely empty or contains only a 
few drachms of blood, hypersemia of the lungs and congestion 
of the pulmonary artery, are seldom wanting. 

In the case of new-born children, Caspar has noticed 
capillary ecchymoses, resembling petechiae, beneath the pul- 
monary pleura, upon the aorta, or the surface of the heart, and 
even upon the diaphragm, which gives the parts a spotted 
appearance. 

The mucous membrane of the larynx and trachea are 






DEATH FROM HANGING, ETC. 301 

more or less injected, of a cinnabar-rod, either in patches or 
Uniformly over the whole surface. A deposit of soot upon 
the tracheal membrane, points to suffocation in smoke. 
There is usually present in the trachea a greater or less 
amount of fluid, consisting of a mixture of air, mucus, and 
blood, in the form of frothy vesicles, or colorless, or bloody 
foam. The more gradual the suffocation has been, the 
greater the quantity of this fluid. It may exist also in the 
bronchial tubes, and can be forced out by careful pressure 
on the lungs. Foreign bodies of every kind may be found 
in the trachea. 

We find also as secondary results of the foregoing, hyper- 
emia of the abdominal and cranial organs. 



3. Death from Hanging, Throttling and Strangling. 

In these cases, death may result from simple cerebral con- 
gestion (apoplexy), from simple congestion of the thoracic 
organs (cardiac or pulmonary apoplexy), from a combination 
of the two (apoplexy and asphyxia), or, as is very frequently 
the case, from neuro-paralysis (nervous apoplexy). 

The internal appearances will therefore vary, or, as in the 
last case, no lesions can be detected. 

The face may in some cases be livid, with protruding eyes 
and tongue ; but in many cases the countenance is like that 
of any other corpse. 

Turgescence of the male and even of the female genitals 
has been noticed in some cases. 

The mark of the cord about the neck may be wanting, 
and is nearly always more or less interrupted, and presents 
many varieties of appearance. It may be of a dirty, yellow- 
ish-brown color, cutting hard and leathery ; or of a bright 
blue or dirty-reddish color, soft to cut ; or it may have little 
or no color, and also soft to cut. Patches of excoriation arc 



o 



02 PATHOLOGICAL CONDITIONS. 



also sometimes visible, if the cord have been bard and 
rough. A similar mark of the cord may be produced after 
death. 

In cases of throttling, the marks of fingers may often be 
recognized, as round or semi- circular, or perfectly irregu- 
lar patches, of a dirty, brownish-yellow color, hard to cut, 
and not ecchymosed. Rarely they are of a dirty-bluish 
color and ecchymosed. 



4. Death from Drowning. 

Physiologically considered, death from drowning is to be 
regarded as identical with death from asphyxia or strang- 
ling, and hence the results of the dissection, do not differ 
from those just mentioned. Those drowned may die from 
cerebral hypersemia, the rarest form ; from pulmonary 
hypersemia ; from both combined ; or from neuro-paralysis. 
Death from hypersemia of the thoracic organs, and death 
from paralysis, are of almost equal frequency in cases of 
drowning. The countenance is pale, in most cases not 
swollen, the eyes shut, and when asphyxia has been the 
cause of death, there is commonly froth over the mouth. If 
the body has been in the water for two or three days in 
summer, or eight to ten in winter, the face is rather reddish, 
or bluish-red — the commencement of putrefaction, which in 
bodies in water, begins in the head and extends from above 
downwards, and not in the abdominal coverings. 

An almost constant appearance is the cutis anserina, a 
phenomenon entirely independent of the temperature of the 
water in which the person has been drowned. 

The hands and feet have a livid, grayish-blue color, and 
the skin is corrugated in longitudinal folds, provided the 
body has not been taken out of the water within about 



DEATH FROM DROWNING. 303 

eight hours after death. Sand, gravel, mud, etc., are often 
found under the finger-nails. 

Contraction of the penis and scrotum in men who have 
fallen into the water alive, is an almost constant appearance. 

The lungs are greatly increased in volume, completely fill 
and distend the cavity of the chest, and are not firm and 
crepitating like healthy lungs, but feel like sponge. The 
trachea and large bronchial tubes are frequently filled with 
frothy mucus. The spasmodic closure of the glottis, will 
prevent the entrance of water into the lungs while life 
continues, but after death it may enter in small quantities. 

In the stomach is often found some of the fluid in which 
the drowning has taken place. 



304 MEDICO-LEGAL QUESTIONS. 

CHAPTER V. 

MEDICO-LEGAL QUESTIONS. 

1. Method of Conducting a Medico-Legal Autopsy. 

In making medico-legal examinations of human bodies, 
the greatest care must be taken not to omit the examination 
and recording of any of the appearances presented ; since 
a point trifling in itself, may, in the course of the subsequent 
legal process, prove of great importance. 

It may sometimes be necessary for the physician to ex- 
amine the exact spot and the locality in which the body 
has been found, to ascertain the position in which it was 
discovered, etc., and also to inspect the clothing. 

In cases of suspected poisoning, the utmost precautions 
are to be used in making the autopsy. All the viscera are 
to be carefully examined, and the stomach and intestines, 
with their contents, are to be removed in the manner 
already described. They are then to be opened, examined 
in separate vessels, either entirely new, or thoroughly 
cleansed immediately before being made use of. After a 
careful examination, they are to be placed in perfectly clean 
or new glass jars, without the addition of any foreign sub- 
stance ; the jars are then to be securely corked and labelled, 
and handed over to the chemist for analysis. Should the 
jars have to remain any time in the hands of the physician, 
they are to be kept under lock and key, in some place to 
which none but himself has access. Portions of other 
organs, especially of the liver, spleen, kidneys and brain, 
should also be preserved with the same care for future 
analysis. 

The results of the examination are to be taken down on 
the spot, by an assistant, in ink, and after having been read 



1IEDJ00-LEGAL QUESTIONS, 305 

through by the physician at the close of the examination, 

are to be signal by him. 

All these precautions will be found of great value, in 
saving from innumerable petty annoyances, at the hands 
of the "learned members of the bar," if the case should be 
brought before court. 

In the external inspection of the body, we should notice : 

1. The Sex. Even after the external parts of generation 
have been completely destroyed, the sex may still be ascer- 
tained by a reference to the growth of hair around these 
parts. A circumscribed arc of hair on the mons veneris, is 
distinctive of the female, while its prolongation, however 
slight, from this point towards the umbilicus, marks the male. 

2. The Age. In the case of known bodies this is not of 
any importance, in unknown bodies it is, however, neces- 
sary. The physician can only conjecture from appearances, 
which, even in the living body, are very deceptive, and he 
will do well, therefore, to allow tolerably wide limits to this 
conjecture. 

3. The Size. The length of the body must be ascertained 
by actual measurement in a straight line, from the crown of 
the head to the sole of the heel. 

4. The General Condition of the Body. Lean or fat, etc. 

5. Color and Condition of the Hair. 

6. Color of the Eyes, if still recognizable. 

7. Nil ruber and Condition of the Teeth. In the case of 
unknown bodies, an accurate description is always advisable, 
with a view to future identification. 

8. Special Marks or Deformities. Scars, tattoo-marks, 
excess or defects of limbs, marks of disease, as ulcers, etc., 
should all be accurately noted. 

9. Injuries or Wmmds, which appear to have been the 
cause of death, should be carefully described. In the case 

20 



306 MEDICO-LEGAL QUESTIONS. 

of wounds, their position and direction with reference to the 
neighboring fixed points of the body, and their exact length 
and breadth, must be recorded. 

10. Of the Body itself, the parts deserving of particular 
examination are the natural openings of the ears, nose, 
mouth, anus and female genitals ; the neck and the hands. 

In the internal examination or dissection, the three great 
cavities — the head, thorax and abdomen — should all be 
opened. In some cases, it may be important to open also 
the spinal canal. 

The first thing to be observed on opening each of these 
cavities, is the position of the organs they contain ; next, 
whether there be any fluid effusions present ; and lastly, 
the external and internal appearance of each separate organ. 
In every case, that cavity should be opened first, in which 
there is the greatest probability of finding the cause of death. 
In the case of new-born children, however, the abdomen 
must be first opened in order that the natural position of 
the diaphragm may be observed undisturbed. 

In examining the base of the skull for injuries, we must 
not omit to remove the periosteum, which might otherwise 
conceal small fissures. 

In examining the thoracic organs, if it be particularly 
desired to observe the amount of blood contained in them, 
and we do not wish to apply ligatures, we examine the 
heart first, leaving it in its natural horizontal position, and 
opening it by a lateral longitudinal incision on both sides. 
This gives us a distinct idea of the actual amount of blood 
in all the cardiac cavities. The lungs are next cut into, and 
last of all the large blood-vessels. This procedure is to be 
followed, e. g., in cases of suffocation, where it is of particu- 
lar importance to determine the amount of blood in these 
organs, and where the blood is peculiarly fluid. 



MEDICO-LEGAL QUESTIONS. 307 

. In determining the amount of blood in the venous trunks, 
it will be sufficient to examine the vena cava ascendens. 

In penetrating wounds, the wound is of course to be ex- 
amined as far as possible before disturbing any of the 



The result of the external and internal examinations, 
thus thoroughly conducted, are to be noted down at the 
time, and are not to be trusted to memory. It is of the 
utmost importance that this rule be observed. 

In presenting a written or verbal report before court, the 
physician should be careful to furnish merely a description 
of the post-mortem appearances, and not to give an opinion 
as to their probable or possible cause or causes, unless called 
upon to do so. He should also avoid prolixity and, as much 
as possible, the use of technical terms, unintelligible to non- 
professionals. 

His answers to direct questions should be concise and 
decided if possible, but where this is not possible, he should 
not hesitate to state that the dissection has not afforded him 
any facts which could enable him to give a positive answer. 



2. Questions relating to New-Bora Children. 

The body of a dead infant is found, and the physician 
may be called upon to answer the following questions, one 
or a ll : — \V as the child mature? Was it born alive? If so, 
what was the cause of its death ? 

Was the child mature f Among the various signs of 
foetal maturity, such as the firm, tense skin, of the usual pale 
corpse-color, the hair upon the head, the weight and length 
of the body, the diameters of the head, shoulders and hips, 
the horny nails reaching to the tips of the fingers, the 



308 MEDICO-LEGAL QUESTIONS. 

absence of the pupillary membrane, etc., the most infallible, 
is the presence of the centre of ossification of the inferior 
femoral epiphysis. " The easiest way to find this, is to make 
a horizontal incision through the skin and superficial tissues 
over the knee-joint down to the cartilages. The patella 
is then to be removed, and the end of the femur made 
to protrude through the incision. Thin horizontal sections 
are then to be removed from the cartilaginous epiphysis, 
at first more boldly, but so soon as a colored point is ob- 
served in the last section, then very carefully, layer by 
layer, till the greatest diameter of the osseous nucleus is 
attained. This appears to the naked eye as a more or less 
circular bright blood-red spot in the midst of the milk white 
cartilage, in which vascular convolutions can be distinctly 
recognized." When there is no visible trace of this centre of 
ossification, the feet as can be no more than from thirty-six 
to thirty-seven weeks old. 

In still-born children, the commencement of this nucleus 
indicates a foetal age of thirty-seven to thirty-eight weeks ; 
when it possesses a diameter of from three-quarters to three 
lines, it shows the foetus must have attained a uterine age 
of forty weeks. When the osseous nucleus measures more 
than three lines, we may conclude that the child has lived 
after birth. 

Isolated exceptions are occasionally met with, when, 
however, concomitant appearances, such as, in the one case, 
defective ossification of the skull, or in the other, peculiarly 
advanced development, will guard us against mistakes. 

Was the child born alive ? or, Did it live during and 
after its birth f and, If so, how long ?■ 

These questions are intimately connected, and in order to 
be able to answer them, we must in our examination note 
the following points : 

The position of the diaphragm, is a good diagnostic sign. 



MEDICOLEGAL QUESTIONS. 309 

Tlio diaphragm will necessarily be higher whore there has 
been no respiration, natural or artificial, than where the 
child has actually breathed. " Its position is most easily 
ascertained by making a longitudinal incision through the 
skin and superficial cellular tissue, from the chin to the 
pubis, in the mesial line, dissecting these from the thorax 
on both sides, next carefully opening the abdominal cavity, 
introducing the finger of one hand into it, and pressing it 
up to the highest point of the concavity of the diaphragm, 
and then with one finger of the other hand reckoning off the 
intercostal spaces from above downwards till both fingers 
correspond. The rule is, that the highest point of the con- 
cavity of the diaphragm in children born dead, is between 
the fourth and fifth ribs, and in those born alive, between 
the fifth and sixth." Where respiration has been but 
transitory, the diaphragm will remain very nearly in its 
fcetal position. 

The lungs, from lying quite posteriorly in the foetus, come 
to fill the cavity of the chest, the more perfectly respiration 
has been established. In the foetus, the left lung is never 
found even partially covering the heart. Where respiration 
has been but transitory and imperfect, the volume of the 
lungs will not be much increased. 

The presence of dark bluish-red, insular patches in the 
lungs, no matter what may be their ground color, proves 
that respiration has taken place. 

The crepitant spongy consistence of the lungs of a live- 
born child, is readily distinguished from the compact, re- 
sistent liver-like lungs of one still-born. 

The hydrostatic test for the presence of air in the lungs, is 
of all, the surest for deciding whether respiration has taken 
place. The vessel used should be at least one foot in 
depth, eight or ten inches in diameter, and filled with pure 
cold water. The buoyancy of the lungs depends upon the 
greater or less completeness with which the pulmonary 



310 MEDICO-LEGAL QUESTIONS. 

tissue is permeated by the air. Only one lung may float, 
generally the right one, or only single lobes, or only a few 
pieces into which the lung has been and must be divided, in 
order accurately to apply the test. Artificially inflated 
foetal lungs, may be distinguished from those lungs which 
have respired, by the presence, in the case of the latter, of 
the bluish-red mottling above referred to, and the escape of 
bloody froth when the substance of the lungs is cut into, 
and slight pressure applied. 

The general appearance of putrescence in the lungs, will 
serve to distinguish the buoyancy arising from the gaseous 
products of putrefaction, from that due to respiration. 

Careful attention to the foregoing points, will enable us to 
answer with certainty whether the child was born alive. 

How long did the child live after its birth f The question 
can be approximately answered with reference to the first 
few days, by attention to the following points : 

If there are no traces of blood, or of that peculiar 
unctious substance, the vernix caseosa, on the body, suffi- 
cient time must have elapsed since its birth, to have 
afforded leisure and opportunity for cleansing it. 

The contraction of the umbilical arteries in living chil- 
dren, does not occur sooner than after eight or ten hours. 
The mummification of the cord commences after two, three, 
or even four days, and the putrefaction only after a much 
longer time. Mummification of the cord takes place as well 
after death as before, but not in water, nor in the liquor 
am nii. If the umbilicus has already cicatrized, the child 
must be at least five days old. 

The stomach immediately after birth, contains a small 
quantity of quite white, transparent, seldom somewhat 
bloody, inodorous mucus, very tough, or a trifling quantity 
of the colorless liquor amnii. If milk be found, it shows 
that some time must have elapsed since the birth. 



MEDICO-LEGAL QUKSTIONS. 311 

In the large intestines meconium is still to he found, 
two, three, or even four days after birth. 

The age of a child, evidently older than five or six days, 
can only be determined hy general appearances. 

What ivas the cause of death f We will here refer only 
to those injuries and kinds of death as can only occur in 
new-born children, and to those post-mortem appearances 
which might lead to error in regard to them. 

During labor, death to the child may result from cerebral 
hyperemia, or from injuries to the cranium, which are 
then unattended by traces of violence on the body, and 
are frequently due to imperfect ossification of the bones, 
detected by holding the bones up to the light after removal 
of the periosteum. 

Prolapse and pressure of the cord, and coiling of the cord 
around the neck, may produce all the appearances of death 
by suffocation. 

The mark of the cord runs uninterruptedly round the 
neck, is broad, circularly depressed, grooved, never excori- 
ated, and everywhere quite soft. A mummified, parchment- 
like, unecchymosed depression, with or without excoriations, 
points to intentional strangulation. 

Subsequent to birth, the child may lmve been killed by 
falling on its head on the floor, if the birth has been very 
rapid. The probable results of such a fall, would be rupture 
of the cord ; premature separation of the placenta, with its 
consequences ; concussion of the brain and hyperemia, or 
actual haemorrhage within the skull ; and fracture of the 
skull bones. The fractures are almost exclusively confined 
to the parietal bones, one or both, chiefly in the region 
of the vertex. 

Comminuted fracture of several bones of the skull, speak 
against an accidental death by a fall. The absence of any 
signs of violent usage on other parts of the body, or about 



312 MEDICO-LEGAL QUESTIONS. 

the head, with simple fracture of the skull, speaks for an 
accidental death. 

The child may also have been suffocated by the mother 
in violent attempts at self-delivery. The visible signs 
of this will consist merely of scratches and nail-marks upon 
the face or neck. Very severe injuries are never produced 
in this way. 

We must be careful not to mistake the common blood- 
eoagulum usually found under the aponeurosis on the child's 
head for the result of violence; nor the folds of the skin, 
in fat children particularly in winter, produced by the move- 
ments of the head, and which remain strongly marked in 
the solidified fat, for the mark left by the cord in a case of 
actual strangulation. 



3. Supposed Period of Death. 

The answer to the question as to the probable time of 
death, is often of the utmost importance. To be able to 
determine this, we must have regard to the various appear- 
ances following death, previous to putrefaction, and to the 
chronological succession of the phenomena of external and 
internal putrescence. 

A. Signs of Death previous to Putrefaction. 

Respiration and circulation have entirely ceased. 

The eyes have lost their lustre. 

There is no vital reaction to stimulants. 

The body grows ashy-white. A particularly florid com- 
plexion may retain its color for some days after death. 

Neither the red or livid edges of ulcers, nor red, black or 
blue tattoo-marks disappear after death. 

An icteric hue existing at death never becomes white, and 



MEDICO-LEGAL QUESTIONS. 313 

ecchymoses retain in every case, the line they had at the 
time of death. 

Most bodies become quite cold in from eight to twelve 
hours. Fat bodies and those of persons killed by lightning, 
or by suffocation, retain the heat longer than others ; in 
water, bodies cool rapidly. 

A general relaxation of the muscular system occurs im- 
mediately after death. 

A body presenting only the above signs, has been dead 
from eight to twelve hours at the longest. 

In from twelve to eighteen hours the eye-balls become 
soft and inelastic, and feel flaccid. 

The muscles on those parts of the body on which it lies, 
become flattened by the weight of the body. 

In from eight to twelve hours after death, hypostases re- 
sulting from the gravitation of the blood in the capillaries, 
begin to form on all the depending parts of the body. 

The most important are the external hypostases — for 
they are liable to be confounded with ecchymoses, and con- 
sequently with traces of violence committed previous to 
death. An incision into the discolored spot should always 
be made, when, if it be an hypostasis — a post-mortem 
stain — there will be no escape of effused fluid or coagulated 
blood, as there will be if it be an ecchymosis, the result of 
violence previous to death. 

The color of these post-mortem stains varies from a livid 
or coppery-reel to a reddish blue. They are extremely 
irregular in form, and are never elevated above the sur- 
rounding skin. They are formed after every kind of death. 

Internal hypostases occur in the brain, in the sinuses and 
veins of the pia mater of the posterior hemispheres, even 
after death from haemorrhage. They must not be confounded 
with cerebral hyperemia. 

In the lungs, hypostases are of constant occurrence, and 



314 MEDICO-LEGAL QUESTIONS. 

are carefully to be distinguished from the signs of ante- 
mortem pulmonary congestion and pneumonia. 

In the intestines and kidneys, hypostases are also noticed. 

In the heart we find no hypostasis, but clots, or "cardiac 
polypi," which are the coagulated fibrine of the blood, 
formed in most cases after death. Their presence proves 
that coagulation of the blood may take place after death. 

The last sign of the earliest stage of death is the rigor 
mortis. It passes from above downwards, beginning on the 
back of the neck and lower jaw, passing on into the facial 
muscles, the front of the neck, the chest, the upper extremi- 
ties, and last of all, the lower extremities. It begins 
variously after eight, ten, or twenty hours, and may last 
from one to nine days. In the mature new-born infant 
it is feeble and very transitory. A low temperature, and 
the existence of alcoholization, favor the long duration of 
cadaveric rigidity. A frozen body is stiff as a board from 
head to foot, whereas in rigor mortis the extremities, par- 
ticularly at the elbows and knees, preserves a certain 
amount of mobility. A body in which only the signs thus 
far mentioned are present, may be presumed to have been 
dead from two to three days at the longest. 

B. The Process of Putrefaction. The progress of putre- 
faction is modified by the following conditions : 

By age. The bodies of new-born children putrefy more 
rapidly than others ; those of very aged persons much more 
slowly. 

By the condition of the body. Fat, flabby and lymphatic 
corpses putrefy more quickly than lean ones, for an abun- 
dance of fluid is very favorable to decomposition. 

By the kind of death. The process is rapid after death 
from exhausting diseases, from injuries attended with much 
mutilation, from suffocation, from narcotic poisons. It is 



MEDICO-LEGAL QUESTIONS. 315 

slower after sudden death in healthy persons, after death 
from poisoning with 'phosphorus, sulphuric acid and alcohol. 

By the access of atmospheric air. Whatever prevents 
this, retards decomposition. Thus, bodies buried in the 
earth, or lying in water, or clothed, putrefy less rapidly 
than those exposed to the direct influence of the air. 

By the quantity of moisture, which in addition to its own, 
can and does reach the body from without. The more 
moisture, the more rapid the process. 

By the temperature of the air, or of the water in which 
the body is lying. " At a tolerably similar average of tem- 
perature, the degree of putrefaction present in a body after 
lying in the open air, for one week (or month), corresponds 
to that found in a body after lying in the water for two 
weeks (or months) , or after lying in the earth in the usual 
manner for eight weeks (or months.") (Caspar.) 

In bodies lying in the air, external putrefaction begins 
with a greenish coloration of the abdominal coverings, in 
from twenty-four to seventy-two hours after death, accord- 
ing to the modifying conditions just noticed. (In bodies 
lying in water, the process of putrefaction begins in the 
face, head as far as the ears, and the upper part of the 
neck, with a livid, bluish tinge, rapidly becoming a brick- 
red, and proceeds downwards in the same relative manner 
as about to be described.) Within the same period, the 
eye-ball becomes soft, yielding to the pressure of the finger. 

After three to five days from the period of death, the 
discoloration has spread over the whole abdomen and 
external genitals, and spots make their appearance on other 
parts. 

In from eight to ten days the discoloration has spread 
over the whole body, and the peculiar odor is developed. 
The abdomen is distended with gas ; the cornea has fallen 
in and become concave. The nails are still firm. 

In fourteen to twenty days after death, the whole body is 



316 MEDICO-LEGAL QUESTIONS. 

of a bright-green, mixed with red and brown. The epi- 
dermis is raised here and there in blisters, and in other 
parts patches of it are quite stripped off. Maggots cover the 
body. From the continued development of gas, the whole 
body is bloated, and has a gigantic appearance. The nails 
are detached at their roots and lie loose, and are easily 
separable. The hair is loose and easily pulled out. 

Since this stage may continue many weeks or even 
months, we cannot distinguish a body in this state after one 
month, from one in the same condition after from three to 
five months. 

After from four to six months, or sooner in the case of 
bodies that have lain in warm and moist media, the cavi- 
ties of the body are opened by the continued development 
of gas ; the skull has separated from the neck, and the 
brain has run out ; the orbital cavities are empty ; all the soft 
parts have commenced to break down into a soft pulp, or are 
partly already broken down and dissolved, leaving entire 
bones exposed. The bones of the extremities are often 
separated by the destruction of the fascise and ligaments. 
No trace of a physiognomy is discernible. The doubtful sex 
of the deceased can only be determined from the external 
peculiarities of form, or the hair about the pubis, or by the 
presence of a uterus, which withstands decomposition longer 
than any other soft organ of the body. 

Internally, the process of putrefaction begins in the 
trachea and larynx. The brain in children up to the end of 
the first year, is next attacked. Next the stomach, intestines 
and spleen, and then the omentum and mesentery. The 
liver is usually compact and firm, even some weeks after 
death. Putrefaction commences on its convex surface. The 
brain of the adult follows next in the succession of putrefy- 
ing organs. Several months usually elapse before putrefac- 
tion of the heart has advanced very far. In the lungs 
decomposition begins about the same time as in the heart, 



MEDICO-LEGAL QUESTIONS. 317 

sometimes earlier. The kidneys, urinary bladder, oesopha- 
gus, pancreas, diaphragm and larger arterial trunks then 
succumb, and last of all the uterus. 



4. The Probable Cause of Death. 

Although in general, a careful examination of a body 
found dead, will readily reveal the true cause of death, 
yet instances frequently occur where attempts at conceal- 
ing it, or peculiar circumstances in connection with the 
death, may render the task more difficult. 

We confine ourselves here to a brief notice of some of the 
more important points to be kept in view, in rightly estima- 
ting the relative value of post-mortem appearances, and in 
guarding against possible mistakes. 

Rough handling, falls and blows, occurring a short time 
after death, may produce excoriations and pseudo-ecchy- 
moses, which cannot by sight be distinguished from such as 
are the result of violence inflicted during life. 

Wounds inflicted during life are distinguished from those 
inflicted after death, by the entire absence in the case of 
the latter, of any signs of vital reaction, as inflammation, 
haemorrhage, suppuration, swelling or cicatrization of the 
edges of the wound, etc. But in the case of very sudden 
death from wounding of an important organ, these traces of 
vital reaction may also be wholly wanting. Again, injuries 
are often produced on dead bodies, by the instruments used 
to recover them from the places in which they have been 
discovered. 

Contused wounds seldom represent the exact dimensions 
of the weapon employed. 

Blunt weapons may merely contuse and disfigure, or 
lacerate, or fracture bones, or produce rupture of internal 



318 MEDICO-LEGAL QUESTIONS. 

organs. Healthy organs never rupture spontaneously, and 
can only be ruptured by external violence. 

The inspection of the position, direction, depth, breadth, 
and number of wounds, compared with the weapon with 
which they have been inflicted, often furnish the means of 
approximately judging of the position of the perpetrator 
when he committed the deed, and even his object and 
bodily strength. 

In judging whether fractures have been produced before 
or after death, we must remember that it is very difficult to 
fracture the bones of a dead body. Hence, for example, 
considerable injuries of the cranial bones, particularly of 
the base of the skull, have most probably been produced 
during life. A fracture of the ribs in the dead body is never 
splintered. 

In deciding whether a case is one of suicide or homicide, 
besides the previous state of mind of the deceased, the 
posture and position of the body, hands, etc., the appearance 
of the clothing, and the character of the wounds or injuries, 
are the points to be particularly noted, as well as the 
absence or presence of evidences of robbery. 

Gunshot wounds produced upon dead bodies, are never as 
deep as similar ones would be in a living body ; the track 
of the bullet can be distinctly traced ; and the edges of the 
wound show no appearance of vital reaction. Hence they 
can readily be distinguished from such as have been 
produced during life. 

Burning of a dead body does not in general produce 
vesication ; by exceedingly intense heat it may, however, be 
produced. The bullae, however, last but a .few minutes, 
never contain serum, but only watery vapor, and never 
exhibit any trace of the bounding line of redness, nor any 
trace of color on their basis. They are, therefore, easily 
distinguished from burns inflicted during life. 



MEDI00-LEGA1 QUESTIO] 319 

In distinguishing between spontaneous apoplexy and cere- 
bra! haemorrhage the result of injuries, it will be sufficient 

to note that, in the former case, but a very small amount 
of blood is effused, so that the discovery of very extensive 
and considerable extravasation of blood within the cranial 
cavity, can be regarded as a proof of the application of 
external violence. 

In the case of a dead body found hanging, it is in most 
instances to be regarded as a case of suicide, unless the 
examination of the body should show external marks of 
violence, or internal signs of death from another cause. 

Where a body has been found in the water ', the question 
may arise whether it was alive or dead when it entered the 
water. The investigation of the body will reveal the cause 
of death. The surest sign that the bodv was alive when it 
was thrown or fell into the water, is the presence in the 
stomach of some of the fluid in which it was lying, if this 
fluid be such as is never voluntarily drank. Whether the 
drowning was a case of suicide or homicide, it is sometimes 
impossible to determine. All the various circumstances of 
time and place, and concomitant appearances, must be 
minutely investigated, in order to hope to arrive at a 
probable conclusion. 

In the case of supposed poisoning, where the fact of the 
administration of poison has been proved, and the person 
has died with symptoms attributable to poisoning, and the 
post-mortem appearances reveal no other cause of death — 
then the death is to be regarded as the actual results of the 
poison, whether its existence in the body can be proved by 
chemical analysis or not. Only such poisons are used by 
suicides as a general thing, as are known to be certain 
poisons, and such as have a very disagreeable taste are, from 
this fact, hardly ever need for the purpose of murder, except 
in the case of very small children, or persons rendered 
insensible by any means. (Caspar.) 



320 EMBALMING THE DEAD. 

CHAPTER VI. 
ON EMBALMING THE DEAD. 

From trie earliest times, the attention of mankind has 
been given to the preservation of the bodies of the dead. 
With the ancient Egyptians, the art was carried to its high- 
est degree of perfection. The motive which led these people 
to devote so much care to this object, is still conjectural ; 
yet it would seem to have originated, in part at least, as a 
sanitary measure, for preserving the purity and healthful- 
ness of the atmosphere. 

While so little is known of the method by which they 
produced such wonderful results, as to have placed the 
process among what have been termed the " Lost Arts," 
yet, from a careful examination of a large number of mum- 
mies, it would appear that the operation consisted : 

First. In the removal of the abdominal and thoracic 
viscera, through an opening in the left side beneath the 
ribs ; and of the brain through the nostrils, by breaking 
through the crebriform plate of the ethmoid bone ; or 
through the mouth, by boring through the basilar process 
of the occipital bone. 

Second. Subjecting the body for a long time to the ac- 
tion of an alkali, (natron,) after having filled the cavities 
with various gums and spices, etc., and thus removing the 
fatty portions. 

Third. A rapid desiccation, after further additions of 
balsams, resins, etc. 

Fourth. Enveloping the whole body in numerous ban- 
dages saturated with gum or bitumen. 

Modern nations, have long practiced evisceration, in con- 
nection with the use of various substances for preserving 
bodies. In the middle ages, the art ol embalming con- 



EMBALMING T11K DEAD. 321 

sisted in mixing aromatic substances with salt, and filling 
the bodies with the same. Henry I. of England, is said to 
have been thus embalmed in 1135. Long and deep 
incisions were made in various parts of the body, these 
filled with the composition, and then carefully sewed up, 
the body afterwards enveloped in a beefs skin, and enclosed 
in a coffin. 

Louis C. Bils, a nobleman of Holland, and Ruysch, a 
Dutch physician, in the latter part of the seventeenth and 
beginning of the eighteenth centuries, acquired great celeb- 
rity from their success in embalming bodies. Both died, 
however, without imparting their secrets to others. 

The discovery of the preservative properties of corrosive 
sublimate in 1762, was soon followed by its employment by 
Chaussier, Beclard and Larrey, in the preserving of bodies. 
Dr. Franchina of Naples, employed arsenic also, with con- 
siderable success ; but from the danger to dissectors, where 
these poisons had been eraplo} T ed, their use after the dis- 
covery of the preservative properties of chloride of zinc, was 
quite discontinued. 

The latter substance, with carbolic acid, constitutes the 
best antiseptis known at the present time, and these are 
more generally employed than any other for preserving 
dead bodies. 

The objects of the process of embalming at the present 
day, are threefold : 1st. It permits the delay of burial where 
this is desirable from the absence of friends; or of the ready 
transportation of the bodies of those who may have died a 
long distance from home, and that free from decay and post- 
mortem change. 2d. As a sanitary measure in large towns 
and cities, where many bodies are placed in family vaults, 
instead of being buried in the ground. 3d. For the preser- 
vation of bodies for the purpose of anatomical study. 

For either of these objects, it is desirable that the pro- 
cess be simple, easy, quick and inexpensive. 

21 



322 EMBALMING THE DEAD. 

Frequently in the large cities, and occasionally in the 
country, the physician will be called upon to perform this 
operation, but without some information upon the subject, 
he will be unable to comply with the request. 

The operation at the present time, consists simply in 
filling the vascular system with a preserving fluid, by inject- 
ing the same into some one or more of the arteries ; the 
substance employed being either carbolic acid or chloride of 
zinc in solution ; the latter, from possessing greater preserving- 
power without the disagreeable odor of the carbolic acid, 
being much more frequently employed. 

Preparation of the Zinc. In the large cities, the chlo- 
ride of zinc may be obtained of the manufacturing chemists 
ready made; but in the country, the plrysician may manu- 
facture the solution himself, by the following process : 

Place in an open stone jar, ten pounds of muriatic acid, 
and add to the same, old scrap sheet zinc, ad libitum. It 
should be frequently stirred, and allowed to stand in the open 
air for from twelve to twenty-four hours, or until the acid 
has so acted upon the zinc as to have become thoroughly 
neutralized, forming thus a saturated solution of the chloride 
of zinc. 

The quantity required of this solution to preserve a body, 
will depend upon the state of the weather, in connection 
with the size of the body, cause of death, etc.; more being 
required in .'hot weather, or in a large body, or in such 
diseases as are followed by a tendency to rapid putrefaction. 
In all cases, however, the rule should be to throw in as much 
as the vessels will hold, varying the strength according to the 
weather, character of the body, etc. • With young, thin 
subjects, and cool weather, the chloride may be diluted one- 
half with water ; but in warmer weather, and with a large 
body full of fluids, a proportion of two-thirds zinc, or even 
stronger may be. required. It will be well to commence by 



EMBALMING THE DEAD. 323 

throwing in a weaker solution, which, by not constringing 
the small vessels, will pass more readily into the extremi- 
ties, and follow by a stronger for filling the large vessels 
of the trunk. 

Dr. Vivodtsef of St. Petersburg, employs a mixture 
of carbolic acid and alcohol. Taking alcohol of about 
ninety degrees, he adds one-fifth its weight of carbolic acid ; 
there being required of this mixture, a quantity equal to 
about one-half the weight of the body to be injected. It 
may be thrown into the vessels in the same manner as the 
solution of the chloride of zinc. The high price of alcohol 
in this country, would constitute an objection to the use of 
this substance, even if it afford advantages over the zinc, 
which it probably does not. 

Instruments Required. For the satisfactory performance 
of this operation, there will be required the anatomical 
syringe. This instrument consists of a brass cylinder and 
piston, of a capacity of twelve to sixteen ounces, with a 
movable stop-cock, and series of graduated pipes for arteries 
of different size. Each pipe has a small rim or shoulder at 
the point to be introduced into the vessel, above which the 
ligature is applied, which thus holds the pipe more securely 
in its position. 

The absence of the anatomical syringe should not, how- 
ever, deter the physician from attempting this operation, 
as, by a little preparation, the common gum-elastic family 
syringe, of the Mattson or a similar pattern, may be made to 
answer the purpose. The point of the small or child's rec- 
tum pipe may be reduced with a file, and a shoulder prepared, 
about one-fourth of an inch from the end, for securely hold- 
ing it when tied in the vessel. 

An apparatus of a complicated character, and working by 
atmospheric pressure, has been, devised for this purpose ; but 



324 EMBALMING THE DEAD. 

while it possesses very few advantages over the syringe 
described, it is expensive and not easily managed. 

The Operation. In the dissecting-room, it is usual to open 
the chest and inject through the arch of the aorta ; but in 
other cases, one of the common carotids, and better the 
right, may be selected. Extend the head, placing thus the 
muscles upon the stretch, and along the inner border of the 
right sterno-cleido-mastoid muscle, make an incision two 
inches in length, through which may be exposed the upper 
portion of the common carotid artery. After detaching the 
vessel from the surrounding structures, it should be raised 
upon the handle of a scalpel and two ligatures passed around, 
one of which is to be tightly tied, high up, upon the vessel. 
Below this, a longitudinal slit, one-half inch in length, should 
be made in the vessel, for receiving the pipe of the syringe, 
which, when in position, should be securely tied with the 
second ligature, just above the ,rim. The stop-cock joint 
may now be fitted to the pipe. 

To permit of the escape of as much of the blood as pos- 
sible, an opening may be made into the jugular vein, liga- 
tures being passed beneath the vessel — one above and one 
below the opening — that it may be closed at the proper 
time. 

The antiseptic fluid having been prepared in a convenient 
vessel, the syringe, after having been carefully examined 
and found in good working order, should be slowly filled, 
adjusted to the stop-cock joint, the cock opened, and the 
syringe slowly discharged. Shutting off the cock, to prevent 
escape of the fluid, the syringe may now be detached, refilled 
and again discharged, the process being repeated until the 
vessels are filled with the fluid, which 'may be known from 
the resistance offered to its introduction. After a few 
syringefuls have been thrown into the vessels, the blood will 



EMBALMING THE DEAD. 325 

be seen flowing more or less freely from the jugular, and 
which will gradually change to the clear antiseptic fluid ; 
then the vessel may be tied, to prevent any further loss. 

To facilitate the flow of the fluid into the vessels of the ex- 
tremities, free flexion and extension of all the limbs should 
be made; and after some minutes, another effort made to 
force in more of the fluid. A successful filling of all the 
vessels may be known by the distension of the superficial 
veins of the chest and arms, accompanied with an escape of 
a dark fluid from the nostrils and, perhaps, mouth, from an 
oozing of the fluid through the capillary vessels of the 
mucous membranes of the head. 

If the extemporized gum syringe be used, its pipe should 
be tied in the vessel as in the other case, the opposite end of 
the tube placed in the vessel of fluid, and the same thrown 
in by pressure of the ball. The operation being completed, 
a ligature should be tightly placed around the artery below 
the pipe, the latter removed and the incision sewed up. 

Changes Resulting from the Operation. As the vessels 
become filled during the operation, the abdomen will grad- 
ually swell, the chest become more round and full, the face 
and eyelids become puffy, while the superficial veins will 
appear full and dark from the contained blood. In a few 
hours the skin assumes a pale, ashen hue, with a parchment- 
like feel, which will be a sure indication of the success of 
the operation. In a few da}^s the puffed appearance of the 
face will have disappeared, when no further change will be 
noticed, until after several weeks the ears, with the tip of 
the nose, and ends of the fingers, begin to shrivel and dry 
up. 



326 PRESERVATION OF SPECIMENS. 



CHAPTER VII. 

PRESERVATION OF SPECIMENS OF MORBID 

ANATOMY. 

Many valuable and interesting pathological specimens are 
continually being lost, from a want of knowledge, or a 
careless neglect on the part of the physician. That the 
fullest benefit may result from a post-mortem examination, 
any rare or interesting specimen should be carefully pre- 
served. Should the physician feel no interest in forming a 
cabinet of morbid anatomy for himself, he should then 
deposit the specimen in the anatomical museum of some 
medical school, where it may be permanently preserved, 
and the profession thus benefited. 

All specimens of soft tissues designed for preservation, 
should first be soaked in water which is changed daily, 
until all blood is removed. If the weather be warm, it 
will be necessary to add to the water each time, either a 
small proportion of alcohol, or some antiseptic, as carbolic 
acid, chloride of zinc, corrosive sublimate, or common salt. 

After all blood is removed, the specimen may be put into 
alcohol of a strength proportionate to the size of the speci- 
men, and then allowed to remain until thoroughly " cured." 
Small specimens are dried up, shrunken and nearly spoiled 
in many cases, by the use of too strong alcohol, while on 
the other hand, large ones, by diluting the alcohol with the 
large amount of water contained, would be likely to spoil in 
a weak preparation. Large specimens, particularly in warm 
weather, should have deep incisions made at a few points, 
for the better penetration of the preserving fluid. 

Before being permanently put up, the specimen should be 
carefully trimmed, and everything interfering with the best 
display of the essential point removed. 



PRESERVATION OF SPECIMENS. 327 

While either of the antiseptics mentioned above will 
answer for " curing " a specimen, for permanent suspension, 
there is no substitute for alcohol. Other fluids may preserve, 
but they will also become turbid, throw down a precipitate, 
and in cold weather are liable to freeze, while from their 
high specific gravity, many light specimens will float on or 
near the surface. If the specimen has been thoroughly 
"cured" before suspension, very dilute alcohol will answer 
for that purpose : equal parts of pure water and alcohol of 
ninety-five degrees, in all except the larger specimens, being 
abundantly strong. Delicate, light specimens will some- 
times float in such a dilution, in which case it should be 
made stronger. 

The best form of anatomical jar is made with ground glass 
stoppers, with a hook on the under side of the latter for sus- 
pending the specimen. Although expensive, these jars, by 
effectually securing the alcohol from evaporation, as well as 
from the greater facility with which the spirits may be 
changed, which will sometimes be required, will give better 
satisfaction than any other. 

Where the common jar without a stopper is used, great 
care will be required in closing up, to prevent loss by evap- 
oration. There should first be prepared a circular plate of 
thick sheet lead, to rest on the top of the neck of the jar. 
The specimen having been suspended by a string, carried 
through by a large needle, and at two different points, is 
to be fastened to the disk of lead by means of two holes, 
punched by an awl, about half an inch apart, near the centre. 
The portion of string above the lead, with the holes also, 
should now be carefully covered with sealing-wax, otherwise, 
by capillary attraction, the alcohol will keep the bladder 
covering continually wet, and finally rot it out. Over the 
lead is now to be stretched a piece of moistened bladder, 
and wound with twine around the neck of the jar. When 
dry, this is to be covered with a coat of black varnish; this 



328 PRESERVATION OF SPECIMENS. 

again when dry, being followed by a second layer of bladder 
and varnish. 

Wet preparations should be kept where they may have a 
free exposure to sunlight. If placed in a dark closet, they 
become damaged in texture, and acquire a dark and unpleasant 
color ; this is particularly the case with the ligamentous and 
nervous tissues. 

Dr. Brunetti of Padua, who has invented a new process 
for preserving certain kinds of specimen, and who received 
a gold medal some years ago at the Paris Exposition, gives 
the following particulars of his method : 

" The process comprises four several operations, viz. : 
1, the washing of the piece to be preserved ; 2, the degrais- 
sage, or eating away of the fatty matter ; 3, the tanning, 
and 4, the' desiccation. 

"1. To wash the piece M. Brunetti passes a current of 
pure water through the blood-vessels and the various excre- 
tory canals, and then he washes the water out by a current 
of alcohol. 

" 2. -For destroying the fat he follows the alcohol with 
ether, which he pushes, of course, through the same blood- 
vessels and excretory ducts ; this part of the operation lasts 
some hours. The ether penetrates the interstices of the 
flesh and dissolves all the fat. The piece, at this point of 
the process, may be preserved any length of time desired, 
plunging it in ether, before proceeding to the final operations. 

"3. For the tanning process M. Brunetti dissolves tannin 
in boiling distilled water, and then, after washing the ether 
out of the vessels with distilled water, he throws this solu- 
tion in. 

"4. For the drying process Dr. Brunetti places the pieces 
in a vase with a double bottom filled with boiling water, 
and he fills the places of the preceding liquids with warm, 
dry air. By the aid of a reservoir, in which air is com- 
pressed to about two atmospheres, and which communicates 



PRESERVATION OF SPECIMENS. 329 

by a stop-cock and a system of tubes, first to a vase con- 
taining chloride of calcium, then with another heated, then 
with the vessels and excretory ducts of the anatomical piece 
in course of preparation, he establishes a gaseous current 
which expels in a very little time all the fluids. The oper- 
ation is now finished. 

11 The piece remains supple, light, preserves its size, its 
normal relations, its solid elements, for there are no longer 
any fluids in it. It may be handled without fear, and will 
last indefinitely." 

For the preservation and hardening of tissues for micro- 
scopic examination — as sections of tumors, glands, mem- 
branes, spinal cord or brain, etc. — Miiller's fluid may be 
employed, which is prepared as follows : bichromate of po- 
tassa, 75 grains; sulphate of soda, 35 grains; dissolved in 
six ounces of w T ater. The specimen should be suspended in 
this fluid until sufficiently hardened to permit of a satisfac- 
tory examination. 



Preparation of Bones. 

Pathological specimens of bones, may be prepared either 
by boiling or maceration. The method by boiling should be 
employed, however, only where the texture of the specimen 
is firm and solid, as in cases of united fracture, etc.; and in 
these cases, care will be required to avoid injuring the 
specimen by too long exposure to the process. Maceration, 
however, is the better method for all cases, and the only 
one to be employed in cases where the bone is softened by 
caries or necroses. 

The specimen having been roughly stripped of the soft 
tissues, is to be thrown into a vessel of water, the latter 
being changed every day, as long as it becomes colored by 
the blood. It is now to be left until the putrefactive pro- 



330 PRESERVATION OF SPECIMENS. 

cess has so softened the tissues that they may be easily 
removed, when, after being thoroughly washed in soda water, 
it may be dried and mounted. If the weather be cold, it 
will be absolutely important that the macerating be con- 
ducted in a warm room, else the process will be so slow 
as to convert the tissues into a form of adipocere, quite 
arresting the putrefactive process, and greatly damaging the 
specimen in its beauty and value. 

In this connection, it may be observed that bones from a 
subject that has been injected with chloride of zinc, can 
never be successfully macerated, the zinc having a sort of 
tanning effect upon the tissues, which enables them to resist 
the putrefactive process. Boiling is the only method by 
which such specimens can be cleansed. 

Where a bone has been properly macerated and dried, and 
especially if from a young subject, it will be found white and 
quite free from grease; but when taken from old subjects, or 
when prepared by boiling, it may be required to be subjected 
to a bleaching process for removing the grease and improving 
the color. By exposure to the sun, with frequent washing 
in chlorine and soda water, the appearance of the specimen 
may be greatly improved, or what is still better, by cover- 
ing the specimen for a few days in sulphuric ether, which 
will effectually dissolve out all th'e grease, and then washing 
and exposing to the sun for a few days, it will be left 
beautifully white and clean. 

For permanent preservation, the specimen should finally 
be mounted on a block or board, in such a manner as best to 
expose its interesting points. 



INDEX. 



PAGE 

Abdomen, method of opening.... 127 

Abdominal dropsy 135 

Alcohol, poisoning by 299 

Anatomical syringe 323 

Anus, diseases of. 157 

fistula of :.... 157 

haemorrhoids 159 

ulcer in 157 

Aorta. (See Arteries.) 

Apoplexy, cerebral 41 

pulmonary 115 

Arachnoid, examination of 38 

Arsenic, poisoning by 297 

Arthritis, chronic rheumatic 271 

scrofulous 271 

Arteries, aneurism of 99 

calcification of 99 

examination of. 98 

fatty degeneration of... 99 

inflammation of. 98 

ossification of 99 

rupture of 102 

Arteries, cerebral. 

atheromatous degen- 
eration of. 60 

calcification of 60 

obstruction of. 59 

position of clot in ob- 
struction of. 59 

Atresia ani 149 

urethra* 212 

Autopsy, medico-legal, method of 
conducting 304 

Biliary calculi 188 

effects of 190 

position of. 189 

Bladder, gall-. (See Gall-bladder.) 

Bladder, urinary. 

contraction of. 210 

catarrh of 210 

cancer of. 211 

dilatation of 209 

examination of. 208 

hypertrophy of. 209 

inflammation of. 210 

malformations of. 208 

parasites in 212 

removal of 131 



PAGE 

Bladder, urinary. 

tuberclesin 211 

tumors in 211 

Bones, abscess of 259 

cancer of 266 

caries of 260 

examination of. 259 

inflammation of. 259 

morbid growths in 263 

necrosis of 260 

rickets in 261 

suppuration of 259 

tumors in 263 

tuberclesin 265 

Brain, appearance of, in health. .. 48 

abscess of. 50 

atrophy of. 53 

blood cysts in 59 

calcareous deposits in 56 

examination of 29 

hardening of 51 

hypertrophy of 52 

hydatids in 57 

inflammation of. 47 

membranes of. 36 

removal of. 29 

softening of 48 

tumors of. 54 

Bright's disease 197 

cirrhotic or contracting 

form 201 

inflammatory form 197 

waxy or amyloid form.. 200 

Bronchial tubes, dilatation of. .. . 125 

examination of.. 106, 122 

inflammation of. 123 

narrowing of. 124 

obliteration of. 124 

Bronchitis 123 

Buccal cavity, examination of.... 65 
Burning, ante - mortem distin- 
guished from post-mortem 318 

Cancer, of bones 266 

black 291 

colloid 292 

encephaloid 291 

epithelial 293 

of gall-bladder 188 

(331) 



332 



INDEX. 



Cancer, of heart 84 

bard 290 

of i ntestines 1 58 

of kidneys 204 

of liver 177 

of lungs 120 

of mammae 256, 257 

of mediastinum 126 

medullary 291 

melanotic 291 

of ovaries 250 

of oesophagus 73 

of penis 217 

of prostate gland 228 

of pancreas 161 

of peritoneum 136 

of spleen 165 

of suprarenal capsules... 208 

of scrotum 219 

of stomach 146 

scirrhus 290 

of testicles 224 

of tongue 68 

of ureters 206 

of urinary bladder 211 

of urethra 214 

of uterus 240 

of vagina 234 

Calculi, urinary 214 

Calvarium, removal of. 28 

Carbonic oxide, poisoning by 299 

Carditis 76 

Cerebral arteries 59 

Cerebritis 48 

Cerebro spinal meningitis 61 

Chest, examination of. 65 

Children, new-born, medico-legal 

question relating to 307 

Chloride of zinc, preservative 

properties of 321 

Colon, removal of 128 

Corrosive sublimate, poisoning by 298 
preservative proper- 
ties of 321 

Cystitis 210 

Death, signs of, previous to putre- 
faction 312 

probable cause of 317 

Diphtheria, false membranes in.. 71 

Disinfectants for instruments 24 

Dropsy of abdomen 135 

of brain 40 

of chest 103 

of heart 74 

of ovaries 248 

of testes 222 

Drowning, death from 302, 309 

Duodenum, removal of 129 

Dura mater, inflammation of... 36, 61 
fibrinous clots in 37 



Dura mater, thickening of 37 

tubercular deposits 

in 38 

tumors in 38 

Ear, examination of. 31 

removal of 29 

Embalming, method of, by an- 
cients 320 

objects of 321 

instruments re- 
quired 323 

the operation 324 

changes resulting 

from 325 

Embolism of cerebral arteries 59 

Endocarditis 77 

Enteritis 149 

Epididymitis 221 

Epispadias 212, 215 

Exostoses 263 

Eyes, removal of 32 

Fallopian tubes, anomalies of 251 

inflammation of 251 

morbid growths in.. 251 

Fistula in ani 157 

Fractures, ante-mortem distin- 
guished from post-mortem 318 

Ganglions 270 

Gall-bladder and ducts 187 

cancer of 188 

dilatation of. 188 

gall-stones in 189 

inflammation of 187 

tumors in 188 

tubercles in 188 

Gastritis 141 

catarrhal 141 

croupous 141 

phlegmonous 141 

Gums, examination of 65 

Gun-shot wounds, ante-mortem 
distinguished from post- 
mortem 318 

Hanging, death from 301, 319 

Hematocele 223 

Haemoptysis 114 

Haemorrhage, pulmonary 114 

uterine 237 

Haemorrhoids 157 

Head, caries of bones of 35 

examination of 27 

removal of membranes of 

brain 28 

removal of calvarium 28 

. removal of brain 29 

thickening of bones of 35 

thinning of bones of 35 



INDEX. 



:;.",:>, 



Heart, atrophy of s l 3 

abscess of. 86 

aneurism of 86 

cancers in 84 

displacements of 87 

dilatation of 80 

ectopia cordis 88 

examination of. 66, 75 

fatty degeneration of 82 

fatty growth of 82 

hydatids in 86 

hypertrophy of 79 

inflammation of. 76 

melanosis of 84 

malformations of 86 

morbid condition of 75 

normal size of. 80 

ossification of arteries of. 85 

rupture of walls of 87 

stenosis of 79 

tumors in 84 

transposition of. 88 

valves of 77 

Heart clots, causes of 91 

color of 89 

consistency of 89 

time of formation of. 90 

position of. 89 

Hepatitis 168 

Hernia 154 

Hydrarthrosis 268 

Hyd rothorp. x 104 

Hydrocele 222 

congenital 222 

diffused 223 

encysted 222 

simple 222 

Hypospadias 212, 215 

Hydrocyanic acid, poisoning by.. 298 

Instruments 21 

disinfectants for 24 

Iutestines, cancer of 158 

contraction of. 153 

dilatation of. 153 

displacement of 154 

examination of 149 

inflammation of. 150 

incarceration of 155 

malformations of 149 

obstructions of. ...155, 156 

parasites in 159 

rupture of. 157 

tubercles in 158 

tumors in 158 

ulceration of 152 

wounds of....". 157 

Intussusception 1 56 

Joints, bursse of, morbid condi- 
tions of 269 



Joints, cartilage of, morbid con- 

ditionsof. 270 

inflammation of synovial 

membrane 268 

malformations of. 268 

rheumatic inflammation 

of. 271 

scrofulous inflammation 

of. 271 

Kidneys, anomalies of 194 

abscesses of. 196 

Bright's disease of 197 

congestion of. 194 

cancer of. 204 

cysts in 204 

dislocation of 203 

examination of. 193 

fatty degeneration of... 202 

haemorrhage of. 195 

inflammation of. 195 

inflammation of cap- 
sule of. 197 

parasites in 205 

removal of. 129 

si#e and weight of. 193 

tubercles in 203 

Larynx, abscesses of. 71 

examination of. 64, 65, 69 

false membranes in 71 

inflammation of 69 

necrosis of cartilages of. 70 

cedema of. 70 

tumors of. 71 

ulceration of. 70 

Liver, abscess of 169, 171 

atrophy of. 174 

blood-vessels of 182 

congestion of 166 

cancer of 177 

degenerations of. 171 

examination of. 130, 165 

effusion haemorrhngic of... 167 

fatty 172 

hypertrophy of. 177 

inflammation of. 168 

parasites in 183, 186 

removal of. 130 

size of 165 

tubercles in 181 

tumors in 182 

Lungs, appearance in health 107 

appearance, post mortem 

118, 120 

abscess of Ill 

apoplexy of 115 

congestion of 107 

cancer of 120 

examination of. 67, 106 

emphysema of 116 



334 



INDEX. 



Lungs, gangrene of 112 

hepatization of. 108 

haemorrhage of. 114 

hydatids in 122 

inflammation of. 107, 109 

melanosis of 121 

suppuration of 110 

tubercles in 117 

tubercular cavities in 119 

tumors in 122 

Mammae, anomalies of. 252 

atrophy of 252 

abscesses of 253 

cancer of. 256, 257 

examination of. 252 

inflammation of 253 

tumors in 254 

ulcers in 254 

Medico-legal questions 304 

external inspection of 

body 305 

internal examination... 306 

Mediastinum, abscess of 126 

cancerous growths 

in 126 

inflammation of... 126 

tumors of 126 

Medulla, spinalis 62 

oblongata, effusions in 43 

of bone, disease of 267 

Membranes of the brain. 

appearance of, in 

meningitis 39 

examination of 36 

morbid changes of, 

in insanity 40 

removal of 28 

serous effusion into.. 40 
sanguineous effusion 

into 41 

Membranes, spinal, tuberculous 

deposits in 61 

tumors in 61 

Meningitis 39 

cerebrospinal 61 

tubercular 38 

Metritis 237, 242 

Metrophlebitis 243 

Morbus Brightii 197 

Mouth, catarrhal or croupous 

inflammation of. 72 

examination of 64 

Myelitis 62 

Miiller's fluid 329 

Neck, examination of 64 

Nephritis 195 

Nitric acid, poisoning by 295 

Nux vomica, poisoning by 299 



(Esophagus, cancer of 73 

dilatation of. 73 

examination of. 72 

inflammation of 72 

stricture of 72 

tumors in 73 

ulceration of 72 

Opium, poisoning by 300 

Orchitis 221 

Osseous growths 263 

Osteomalacia 262 

Osteophytes 263 

Ovaries, abscesses in 247 

cysts in 248 

dropsy of 248 

examination of. 247 

inflammation of 247 

malignant disease of 250 

tumors, tubercles, etc., 

of 251 

Oxalic acid, poisoning by 295 

Palate^ examination of 65 

Pacchionian bodies 39 

atrophy of. 161 

Pancreas, anomalies of. 160 

cancer of 161 

dilatation of ducts 161 

examination of. 160 

fatty degeneration of.. 161 

hypertrophy of 161 

inflammation of 161 

removal of 129 

Parasites in bladder 212 

in brain 57 

in heart 86 

in intestines 159 

in kidneys 205 

in liver 183, 186 

in lungs 122 

in spinal cord 63 

Pelvic viscera, removal of. 130 

Penis, anomalies of 215 

atrophy of 215 

balanitis of. 216 

chancres on 216 

cancer of... 217 

examination of 215 

fracture of 216 

hypertrophy of 215 

herpes of 216 

paraphymosis of. 216 

psoriasis of prepuce 216 

tumors of 218 

warts on 217 

Pericardium, adhesions in 74 

blood in 74 

examination of..... 73 
inflammation of. ... 73 
morbid growths in 75 



INDEX. 



335 



Peritoneum, blood in result of 

violence 135 

congestion of. 133 

cancer of 136 

dropsical accumu- 
lation in 135 

exudation, fibrin- 
ous, on 134 

examination of 133 

gangrene of. 135 

inflammation of..... 133 

suppuration of. 135 

tubercular deposits 

in 136 

tumors of. 136 

Peritonitis 133 

puerperal 243 

Perihepatitis 167 

Peripractitis 151 

Perityphlitis 151 

Pharynx, examination of 65, 72 

inflammation of 72 

tumors in 73 

ulceration of. 72 

Phosphorus, poisoning by 296 

Pia mater, examination of 38 

inflammation of, in 

spotted fever 61 

Pleura, adhesions in 103 

examination of. 103 

effusions into 103 

inflammation of. 103 

Pleurisy 103 

Pneumonia, catarrhal 109 

croupous 110 

double 109 

lobular 110 

single 109 

Pneumothorax 105 

Poisoning, death from 294 

Post-mortem examinations 24 

preliminary pre- 

« parationsfor... 24 

in medico-legal 

cases 304 

Pregnancy, abdominal 244 

extra uterine 244 

tubal 245 

utero-tubal 245 

Preparation of bones 329 

by boiling 329 

by maceration 329 

bleaching of. 330 

Preservation of specimens of 

morbid anatomy 326 

process of Dr. Brunetti 328 

Prolapsus of rectum 157 

Prostate gland, anomalies of. 227 

atrophy of 228 

cancer of 228 

cysts in 228 



l Prostate gland, concretions in.... 229 

examination of. 226 

hypertrophy of. 227 

tubercles in 228 

tumors in 228 

anomalies of. 230 

Pudenda, examination of 230 

elephantiasis of. 232 

hypertrophy of 230 

inflammation of 231 

tubercles in 232 

tumors in 232 

warty excrescences on. 231 

Putrefaction, process of 314 

Pyelitis 196 

Pyelonephritis.. 196 

Questions relating to new-born 

children 307 

was the child mature? 307 

was it born alive ? 308 

how long did it live?.. 310 
what was the cause 
of death? 311 

Rachitis 261 

Rectum, prolapsus of 157 

removal of. 128 

Sclerosis of spinal cord 62 

Scrotum, cancer of. 219 

examination of. 218 

elephantiasis of. 218 

hypertrophy of 218 

inflammation of 219 

Seminal vesicles, anomalies of.... 226 

examination of. 226 

inflammation of 226 

tubercles in 227 

Signs of death 312 

Skull, caries of bones of 35 

examination of 34 

fracture of 34 

thinning of bones of 35 

thickening of bones of..... 35 

Spinal cord, atrophy of. 63 

examination of 60 

inflammation of mem- 
branes of 60 

morbid growths in 63 

parasites in 63 

preservation of speci- 
mens of 33 

removal of 33 

softening of. 62 

Spinal column, disease of. 272 

Spinal canal, serous effusions in.. 61 

Spina bifida 61 

Spleen, anomalies of. 162 

atrophy of 162 

cysts in 165 



336 



INDEX. 



Spleen, cancer of. 105 

displacements of. 103 

degeneration of 164 

examination of. 162 

hypertrophy of. 162 

inflammation of 163 

removal of 129 

rupture of 163 

size of, normal and ab- 
normal 162 

thickening of capsules 

of 164 

tubercles in 164 

Spotted fever, inflammation of 

pia mater in , 61 

Stomach, atrophy of. 145 

Beaumont's experi- 
ments on 140 

cirrhosis of 144 

cancer of 146 

cancer in, results of..... 148 

dilatation of 145 

examination of. 137 

erosions, hemorrhagic, 

of 143 

inflammation of. 140 

post-mortem changes 

in 137 

poisons in, and their 

effects 142 

softening of 143 

tumors in 148 

ulcers in 142 

Strangling, death from 301 

Strychnia, poisoning by 299 

Suffocation, death from 300 

Sulphuric acid, poisoning by 294 

Suprarenal capsules 207 

cancer of. 208 

cysts in 208 

haemorrhage of 208 

inflammation of. 207 

tubercles in 208 

Testicles, atrophy of 220 

anomalies of. 219 

cancer of 224 

cystic disease of 225 

dropsy of 222 

examination of 219 

haematocele of. 223 

hypertrophy of. 220 

inflammation of 221 

tubercles in 225 

tumors in 226 

varicocele of. 223 

Teeth, examination of. 65 

Throttling, death from 301 

Thrombi in sinuses of dura 

mater 37 

Tongue, cancer of 68 



Tongue, examination of 68 

hypertrophy of 69 

ranula of 68 

syphilitic ulcers of. 68 

tubercles of 68 

tumors of. 68 

Tonsils, catarrhal or croupous 

inflammation of 72 

examination of 65 

Tubercular disease of lungs 117 

tubercular cavities 

in 119 

meningitis 38 

Tumors, adenoid 285 

benign 274 

in brain 54 

in bones 263 

in bladder 211 

classification of 274 

cystic 274 

cartilaginous 280 

carcinomatous 288 

in dura mater 38 

fatty 279 

fibrous 279 

in Fallopian tubes 251 

in gall-bladder and 

ducts 188 

hydatid 277 

in heart 84 

in intestines 158 

lipomatous 279 

lymphatic 285 

in larynx 71 

in lungs 122 

in liver 182 

myxomatous 278 

myomatous 284 

malignant 286 

in mediastinum 126 

in mammae 254 

neuromatous 284 

osseous....*. 281 

in oesophagus 73 

in ovaries 251 

papillary 282 

polypoid 283 

in pharynx 73 

in pericardium 75 

in peritoneum 136 

in pudenda 232 

in prostate gland 228 

in penis 218 

sarcomatous 286 

in spinal cord 63 

in stomach 148 

in tongue 68 

in testicles 226 

in uterus 238 

in vagina 234 

vascular 284 



INDEX. 



337 



Ureters, cancer of 206 

cysts in 207 

defects of. 205 

dilatation of. 206 

inflammation of 206 

tubercles in 207 

Urethra, contraction of 213 

cancer of 214 

dilatation of. 213 

inflammation of. 212 

malformations of 212 

rupture of 213 

stricture of 213 

tubercles in 214 

warty growths in 213 

Uterus, anomalies of 235 

atrophy of 236 

cysts in 240 

cancer in 240 

examination of 235 

excrescences, cauliflower, 

etc 241 

hsematom etra 236 

hypertrophy of 236 

hydrometra 236 

haemorrhages of 237 

inflammation of, 237, 242, 243 

malpositions of. 236 

removal of 132 

rupture of 241 

tubercles in 240 

tumors in 230 

ulcerations of 238 



Vagina, anomalies of 232 

dilatation of 232 

examination of. 230 

gangrene of 234 

inflammation of 233 

laxity of. 232 

laceration of 232 

rigidity of 232 

rupture of 233 

stricture of 232 

tumors of 234 

Valves of heart, aneurism of 79 

atrophy of. 78 

calcification of... 78 
contraction of... 79 

thickening of 77 

Volvulus 156 

Vulva. (See Pudenda). 

White swelling 271 

Wounds, death from 317 

contused, appearance 

of 317 

post - m ortem disti n - 
guished from ante- 
mortem 317 

Zinc, preparation of, for embalm- 
ing 322 

quantity of, required 322 



ERRATA. 



On page 21, last line, for "cnlvarium," read calvarium. 
" 25, fifteenth line, for "collodian," read collodion. 

" 79, last line, for "that organ,'' read those organs. 

" 93, thirteenth line, for "affords," read afford. 



